<%BANNER%>

The Relationship of Spirituality and Self-Health Assessment in Predicting Postoperative Pain and Analgesic Use

xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20110115_AAAABX INGEST_TIME 2011-01-15T13:20:48Z PACKAGE UFE0008386_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 1053954 DFID F20110115_AABIJW ORIGIN DEPOSITOR PATH mcnally_p_Page_027.tif GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
f1f18f5ade7b7b0fa6da57dd7974d0f8
SHA-1
02be662a679151a625c5f99e9ef21428fea50954
F20110115_AABIKL mcnally_p_Page_043.tif
822b9ce02d0fe7f24e85fdfac235d8f6
1414817a516361d8fac77891fea863bc2f0d6d3e
F20110115_AABIJX mcnally_p_Page_028.tif
ba0f4ea1b82a3972fbc378156a8e7d8e
0d3c73fa55b09437a56b29f4eba8a7fe1beb491e
F20110115_AABILA mcnally_p_Page_058.tif
f7dfa9bcedf13c866725af22da8b7ffa
59bd18b896b0d570d48d400b909cd8ac3743db92
F20110115_AABIKM mcnally_p_Page_044.tif
51f11b47de232e6d9ea7a6a22901b980
3a9639fa9394bbb22f58d79a89d834adb39e3492
F20110115_AABIJY mcnally_p_Page_029.tif
4932655433f48371c5b1312d3814c913
eef71eb25105642d091530c9097d9200fd9464e7
F20110115_AABILB mcnally_p_Page_059.tif
4cf90305923626f797215f327847aef1
40bdd6e0e4da23035eeef6dfc2292fd59f85403e
F20110115_AABIJZ mcnally_p_Page_030.tif
e7c028dc25a0b02066743c4585322ec4
a2e6dcc2a45ee45a8c2b0dae01f3c818691fdb57
F20110115_AABILC mcnally_p_Page_060.tif
780575a2f5f76ce712cc194c66835129
420bff39d3165d4e6ea0b455ac4cb3b119bef0ce
F20110115_AABIKN mcnally_p_Page_045.tif
1c78dadad3428d488596f0a6948012cc
f47a6aac03d77a83333c1865c76acc24995c06b3
F20110115_AABILD mcnally_p_Page_061.tif
c08282fba5da23dbb82721f82c74ff71
50bdd0cb3898f5307f4897e11362ab1020ad189f
F20110115_AABIKO mcnally_p_Page_046.tif
24c2fe6df85089c6f6f1d070cafb9ee8
fcb59b255b5834aaa10a3ed6a545aa05e103d6e4
F20110115_AABILE mcnally_p_Page_062.tif
03123336e7b4050eb1a6c1d3afd371af
66eb3123d87e3730394760f555b1ce64fb6dc5a8
F20110115_AABIKP mcnally_p_Page_047.tif
7cc23ceb6a0f4e494db930c02a4b4db0
d887661a7ca53d87abec04f623e427e9f7889d7b
25271604 F20110115_AABILF mcnally_p_Page_063.tif
61de3c6b3e19cd0fb0131a8e840a66ae
dd38981a123737998f608c6ea831d79d4f2baba2
F20110115_AABIKQ mcnally_p_Page_048.tif
4c32c8b8545c87c22adb7fcd3bb000ca
c63fed7b438226c9b31a2d6e923002ca85b58b92
F20110115_AABILG mcnally_p_Page_064.tif
247ed0885638975c021609e5435910f8
c06fb51d65ab30197bd3529b8d2b9e9238e2b37a
F20110115_AABIKR mcnally_p_Page_049.tif
95b329f0ac30a201628eb1ec6a1185cc
a4c20676ba48f53fbf1735a473d602c2a0c3393d
F20110115_AABILH mcnally_p_Page_065.tif
3964b1bf0995046e57b009b8791a3569
6503b10033e6dfec7e8e1b3d0b07f512bcab43a0
F20110115_AABIKS mcnally_p_Page_050.tif
69a0d6464ecd175105399e3c2c1f7931
b8ab3ba95b1bf45b85f153462e9fb875533ca17e
F20110115_AABILI mcnally_p_Page_066.tif
083e948598db11685cea8dd8a05c61eb
df697cd6ed1c3eff4e90ca058605f988795c2f95
F20110115_AABIKT mcnally_p_Page_051.tif
2003349c3a7098ad606428a89f8a84fa
3a54f2fbc47eec0b5341883a00e3c41b8da04973
F20110115_AABILJ mcnally_p_Page_067.tif
5f334b74248312344a510b2196b3d162
02985fc22796032f80ceda7d55d2c6105939449a
F20110115_AABIKU mcnally_p_Page_052.tif
6fa047f2b7d81d6f68447f8a3c7c8479
a38c6d6f2dd2b61b951911648658729220276228
F20110115_AABILK mcnally_p_Page_068.tif
3931041caddad540349833ca74ae8228
f4c5f6a2c06cd16d734646935579878648b3bf4b
F20110115_AABIKV mcnally_p_Page_053.tif
246fab098c7bc2ac0f5bda034cad6ae1
bb2c51a406dfba5f40e0aada1a17e99ab0d6f458
F20110115_AABILL mcnally_p_Page_069.tif
84b0c6568a564eef37b79924123a2a50
e5c1a08cc4f541aa51aa079c027fee8d8380d68b
F20110115_AABIKW mcnally_p_Page_054.tif
e6c23f86566763d9bbcf84ccbffcdf81
993817fe85021ca54b6487f5152aaf053e0d36cf
F20110115_AABIMA mcnally_p_Page_084.tif
95c3219e136c941f7336e7acf7faa6a7
6791449441e9efb57bc44c5de1a1fd8d9f5b3b93
F20110115_AABILM mcnally_p_Page_070.tif
633d30c548fe8d4f7f427082f11376b1
7d0aa0a3b4ba4ac8f6b5f802a6660a88ec7f2f40
F20110115_AABIKX mcnally_p_Page_055.tif
5df89e65e12975238f3b5abf78f1f27f
2b5b65705a9368a2e7026546b1e2cf96c46491d8
F20110115_AABIMB mcnally_p_Page_085.tif
7fda102e650c15bbbfb40954261d24a3
e0144717174be42c18446906f143316ca2b4dc59
F20110115_AABILN mcnally_p_Page_071.tif
17c6c3e527b6a3308fceba7076cfd33c
f6f73d1d3446aa8bdb3cd6e68c17ba1c41223aac
F20110115_AABIKY mcnally_p_Page_056.tif
6699b6cdf4b78d1bd42cbd0e09fa86de
5ceb8b456396d8ae6e971e763ad6e8e499882d2d
F20110115_AABIMC mcnally_p_Page_086.tif
115d15b7e54e98cc593fe6066cd3df1d
9c4e89846a70fbb113eb63080098cf5e9f75a83e
F20110115_AABIKZ mcnally_p_Page_057.tif
6d5a716ae1729908560c4923efae803a
8ab1673b0eb493770e1a9e3c8e7ac4d1aa2f3583
F20110115_AABIMD mcnally_p_Page_087.tif
70dab58bdf88ef8d23da14b238e31bc2
28467b65d062c35841ebda3495a0ff576d4e8f01
F20110115_AABILO mcnally_p_Page_072.tif
5926fd84134a40035eb229fc3acb3f43
7d7820d233ec750e285641ce64517da883afdd99
F20110115_AABIME mcnally_p_Page_088.tif
abbe3076d6fea8793c76365531789918
86ac2656a85f7aa8bca52e0a75db27b30de169d7
F20110115_AABILP mcnally_p_Page_073.tif
22a7e5667403a952bdaaff1fd7e6b887
922a6e08c550731c397e7dd0751ef517a69465d7
F20110115_AABIMF mcnally_p_Page_089.tif
fc9eca03e6b349780883edd077cc9e17
1f0ba1f54c35c304d0eaa7b5f7cd769cd55ccb4a
F20110115_AABILQ mcnally_p_Page_074.tif
bf134a157048e592832be98b8c48bb77
965aa3646e67523c905329657d9a70f1fe04d4c2
F20110115_AABIMG mcnally_p_Page_090.tif
92da10506e5d6bde2951c12c6831af0c
5703855cec492823405e791e6c82d71bf7368c0c
F20110115_AABILR mcnally_p_Page_075.tif
eb02dc3128012f0632672b51ed49b43b
af743e7883781d0df7dfb551e201dd6a0dd36737
F20110115_AABIMH mcnally_p_Page_091.tif
d3fc76f3d6e8e1edcb26181499d1dd61
f10f8e76789410b6fdaa79c1efd504c1c702f796
F20110115_AABILS mcnally_p_Page_076.tif
86ab258e02ac37dcd80f77f19406a067
c6a35ca2210f18f958200bd269b259e5ade2a1a9
F20110115_AABIMI mcnally_p_Page_092.tif
797c1fe4dbe2094ef0e57d832b599413
7d471a112d5436d0d07a1912a706331df20c23a2
F20110115_AABILT mcnally_p_Page_077.tif
f96a7f400f977e0c8bbbdc155e3705a6
a612993cb07b5798fdbcbecf607bf406ef209aa7
F20110115_AABIMJ mcnally_p_Page_093.tif
03de1a10792c19cb2697b4744b691d25
6dea56076f80ae5053e8fb05d84bf91a096d0381
F20110115_AABILU mcnally_p_Page_078.tif
f6ac3f2b6f42d7074bf735150399b6a7
22319ee5b89ffff3af2bca363c07d3089477e3e3
F20110115_AABIMK mcnally_p_Page_094.tif
c3fc1d535a55c0addefedeb0b2e24601
5163a6fc2ffc79d080c34de8412f8a8b952d91b9
F20110115_AABILV mcnally_p_Page_079.tif
cf5a79fc64c27679f05ee1cdf851e567
ba854501f5c5a26b74e7b22bcb774d6ec657021d
F20110115_AABIML mcnally_p_Page_095.tif
ca5698610c18affc0fcdec61bbab3fe6
985afeaae07e76b88f823570c6af7a5f25fbc34a
F20110115_AABILW mcnally_p_Page_080.tif
1eac4654b472f65ded74e945d0cee869
e950ac97631ca05c5894e6594a3e3be045a40f89
F20110115_AABIMM mcnally_p_Page_096.tif
f705000c3d0534b172b46a462413dffa
d256b9534fc31ce64004ab99b8f864179e831479
F20110115_AABILX mcnally_p_Page_081.tif
9e3e17802af633bd33a201c65aaf62e2
e8d9c28724552596197bef5d7964b527507ef0b4
33672 F20110115_AABINA mcnally_p_Page_008.pro
3307466536db3abb1c07b749058061a9
ee680020360adc954f38d7d2b4fb1fe136bd2be0
F20110115_AABIMN mcnally_p_Page_097.tif
60eb0289bb276b4d419cb8dda62f6db6
6e868283c93e3f7933489138bb9cbef6fca68269
F20110115_AABILY mcnally_p_Page_082.tif
9f682c3b8cf22a3bdc7ecfac6bed6ca7
14fc6fd17ac01d3b7ca8c195b09c0e6beee98ccd
37070 F20110115_AABINB mcnally_p_Page_009.pro
9ad268a87009be165221e7fa681d9fb0
b2f3a3270cbed662cd1f3ec7ab1ee5e02fd559b4
F20110115_AABIMO mcnally_p_Page_098.tif
05c3dc8cade19b721e38ea2e7c9dee30
7f5ad52d4788996bb6750cc17e7b5eb2185d27ea
F20110115_AABILZ mcnally_p_Page_083.tif
808a1a8c686bec7b20beae0f5227d2b9
62cee65be124f0fafb8e93f7c080a687b70c049a
46622 F20110115_AABINC mcnally_p_Page_010.pro
e268840b578a154a5382efbcf3fb6f51
644d421ea49e1e14712140eb6ea76f5782803f41
42381 F20110115_AABIND mcnally_p_Page_011.pro
5f59fc3e3318830d48314646398f32c6
cd8f6521e1fd1478f103e5fdd3c3918ee55ff167
F20110115_AABIMP mcnally_p_Page_099.tif
b69affb24a27c8a195b9fa3b966f4acd
85f05b6e8fa7fc039f9716368de79b27694800f2
48593 F20110115_AABINE mcnally_p_Page_012.pro
005a8bb76bb9f9ff283cc38074d53392
b6a511f1d51c1581a521d87871852754828ec323
F20110115_AABIMQ mcnally_p_Page_100.tif
512f92a0433db164a0180f7c95c1cde6
4c9be07060fd3364cbdb7e69840bbeec27167db8
43310 F20110115_AABINF mcnally_p_Page_013.pro
c32c5d31ff7b8c87f0b9cd2f002ef9d1
7607505769cc5dc80fb4becd8f483c240977d33c
F20110115_AABIMR mcnally_p_Page_101.tif
6d0018db3afcf9c57052539dce1aedfa
86c2547bd92503a85b7e6c0893cf784ecb9f1393
49440 F20110115_AABING mcnally_p_Page_014.pro
5b0f0b3b50497b70b8b9cba3e83ab39c
c5e52a31ce3536253ffbffbe7c42a7c287335d3c
F20110115_AABIMS mcnally_p_Page_102.tif
e6292b0ff91e79a6ce06b37846a7cceb
d09caf1318fe4796dd4b30fdff667809de2b0456
49275 F20110115_AABINH mcnally_p_Page_015.pro
07db7ef3d3cc23038c72df177c788f70
84bca935d42ec4e96c7cf866b2fa1c923e55b068
9079 F20110115_AABIMT mcnally_p_Page_001.pro
a658423bfc9bbe5c5ae73e9e92219bb6
73b53bf899d98a4b3c435d6985403bcddaa4f7fe
48241 F20110115_AABINI mcnally_p_Page_017.pro
1b70a78c171577d3ad4f6f04ece328e5
925d0fd16a1414fecd4b7d5fc430341af43d87e7
1280 F20110115_AABIMU mcnally_p_Page_002.pro
d06023419eb75dc7f14ea9ae7433d78c
b3b98b8d1316fe0c7adbe460396f7815cca42cb4
42934 F20110115_AABINJ mcnally_p_Page_018.pro
9be8ae4c733760a45b9084303ad71b6d
9752180ef34c1de159ce800b69b1c1dd401e244e
626 F20110115_AABIMV mcnally_p_Page_003.pro
db4a1f18cb47f46fa01f990e3ab566f6
d28690639e8b4bb86aa5abfc34429680877a07fb
43672 F20110115_AABINK mcnally_p_Page_019.pro
348aa98a79e78d70ea8e36f041efe4e5
66aecb6e639833a13578197613655ba7fdfecc89
39681 F20110115_AABIMW mcnally_p_Page_004.pro
0c6e6bbb293d42d776df8bdba1ad651c
da1ce9b33306092d38d7fcfe20a170226a3620d9
45093 F20110115_AABINL mcnally_p_Page_020.pro
55dbd2ca3e028f672c5826f16abbfe69
4b2465185bc3c3f4e0666056583a10f38025c8f4
81130 F20110115_AABIMX mcnally_p_Page_005.pro
1b248323440c04439b442fc3b74edfd8
3ca95d87d410614e283dcbe239db0d2c861b7488
45111 F20110115_AABIOA mcnally_p_Page_036.pro
4edc26ec76e5850453475591c3b89e03
29b9d5a2661672f7bce9ea90299aab05f809d828
44589 F20110115_AABINM mcnally_p_Page_021.pro
7c30eff9e7d72998c34dca8ce2c7bc3d
157e4c21e126b6b8a625af2d47a4d5e00430239d
90582 F20110115_AABIMY mcnally_p_Page_006.pro
3dbb7988d3e7ce20f74b05b0bce83b09
86d0914c8fa2bc51ed5e8519b4523586dc7135e4
48141 F20110115_AABIOB mcnally_p_Page_037.pro
3152875ea6e514b9563c5aa42ea4a789
c96505c91089483c64d01865efdaadac69f4ac85
49280 F20110115_AABINN mcnally_p_Page_022.pro
8e832aabfcadf1634e029890e36ac295
84b7341d01907835ad579752a467e324e8c0e321
13766 F20110115_AABIMZ mcnally_p_Page_007.pro
9aea1fef80a406cdd679a390bf84aa50
4bcb5c56132c65b7c7e0b27f41ba658924e018c0
45543 F20110115_AABIOC mcnally_p_Page_038.pro
b3a5a0ab288647d819c30483735bbf4d
0a81cfc87e0a926ed794b37a3a8ff61e37101f24
48384 F20110115_AABINO mcnally_p_Page_023.pro
2eda4b3138724b908219875048c5dc0b
7ff766e36b2ffbc14bd7a78d693f123b279d1f25
42362 F20110115_AABIOD mcnally_p_Page_039.pro
8d1463954781f9b1e32429e7033ad724
6b9df4b3e0296ad6ce6e9033d54a0dcbbdd82a66
48840 F20110115_AABINP mcnally_p_Page_024.pro
b5fe76720353a4e6eb69e6215ea174e0
953bd93c1e18414aa2b76c14209e499a82a99c8a
45898 F20110115_AABIOE mcnally_p_Page_040.pro
be8cfac107828f419c375921efe152d8
ceaa469867e8a3ef63eaf9aa6f768dfedaffdc52
10199 F20110115_AABIOF mcnally_p_Page_042.pro
a96a8013e35163b567a81cda0fcf4911
85b5a486e885c4d3884ea9b201e7fc2920c3bc4f
49962 F20110115_AABINQ mcnally_p_Page_025.pro
203bcba1f2651c0ebe420d9ced70ad3c
259cef021eaafa845c2f5f2494cb20588bb67737
42398 F20110115_AABIOG mcnally_p_Page_043.pro
2fde2b9b122b33da3b311c8de1dbc872
39c453e2ccf6e0b40287ff1c8235f055cfe953bd
51372 F20110115_AABINR mcnally_p_Page_027.pro
c6ac58ddbc9be27dda61a98a5d9b6422
e5333a913a81421c363c33c426773cd28e6a2fe1
40851 F20110115_AABIOH mcnally_p_Page_044.pro
892ce98d169ee44c98a8df69351dc89c
5632f1badab295ce8e152f038d07804ec71117be
52827 F20110115_AABINS mcnally_p_Page_028.pro
be9ba15648bb2c7935f3a54a441ea6fc
a98cce07acd64575a800abb0786ad1044c0bed32
46479 F20110115_AABIOI mcnally_p_Page_045.pro
e332b6e93da5f10cafa5010ad4312044
8fa3dd7c7e1eb797c40e148337bcb9d3271870d7
52260 F20110115_AABINT mcnally_p_Page_029.pro
aa55221b06a3f7ea20128ca5608ccb16
ed141a2917606319e9ba13e1b569a7ef400b2918
48298 F20110115_AABIOJ mcnally_p_Page_046.pro
bdeaa46b6e45cce859b41444c752d0eb
39931146d30ff76b9f7c6e2c4b84055037c7a12b
53151 F20110115_AABINU mcnally_p_Page_030.pro
6defe128a08bc561c96209aceb45245a
b0863fb03fe6c0fffc8768bae16bfaa8aa9ca81d
49420 F20110115_AABIOK mcnally_p_Page_047.pro
c209dfd9304e573f8b48730ba5b69b0b
babc74182dfa42cf82649919c0e14df57e3f5197
48193 F20110115_AABINV mcnally_p_Page_031.pro
1b414e783b5cc65b38e98d61c29c7a30
01a3bbe87138b556c1d112ec3b1754943d5d84f7
38573 F20110115_AABIOL mcnally_p_Page_048.pro
6c57bec6ec675c3a42c4b0698b4ce5c0
d7b5eb77ad66b438d31a0e6a074b0f9668ae8d8d
40731 F20110115_AABINW mcnally_p_Page_032.pro
b6e4f230dfc97cbaa4d536134310fae3
9452d96f08c7897a8a4de47536f1ceb21a03a4a8
24898 F20110115_AABIPA mcnally_p_Page_063.pro
2c302139242a5e3ec7b15421af97dd6e
fbac64b7c9b1e18f3b05697cde2ca6114f84503a
37200 F20110115_AABIOM mcnally_p_Page_049.pro
64da4c673521e2d7dc8a219ecede68e1
ea9ec0d38c321050f5eba943347aa3458f2093b6
38097 F20110115_AABINX mcnally_p_Page_033.pro
4272f03bae04ab7a7a5af21dccd16256
9c5ce1e9656c76ff304f388e97665328a22a2df3
1551 F20110115_AABIPB mcnally_p_Page_064.pro
96f99e449e1f8df093974a64f78a3541
0c61c72e71366c4f3ce3906ab550ce19de442064
27056 F20110115_AABION mcnally_p_Page_050.pro
a8a888690f9b851233eac2468564664a
24ccb8a21a39b77750814f4c5408e123cf8cc372
40798 F20110115_AABINY mcnally_p_Page_034.pro
bbc4eacd4f771c2455df51ebbe8cd7d9
8c217c31d1a28c2a7fa81933304fb572a02cd198
48002 F20110115_AABIOO mcnally_p_Page_051.pro
e2b45dd936e8a811829f2cab79f3ac36
1d668681dbbb72706613e9b4d1312aaa4c16d61c
36909 F20110115_AABINZ mcnally_p_Page_035.pro
6196e70fc686554142a9a87fb473c964
c0959ebd766f2e5e4d803a0505d31cd41c71cd78
35198 F20110115_AABIPC mcnally_p_Page_065.pro
2647fcef240988fead0c1a0daed8d4ba
0eeec9794060b22be7dea1f2c63a0479c0dffcda
48876 F20110115_AABIOP mcnally_p_Page_052.pro
ee5b5acf43eb3669c81556bb9c408dc9
681c9e29bc1a016bc96bd34bf9464e6a92fbe221
65961 F20110115_AABIPD mcnally_p_Page_066.pro
008689e482e87f6f2df6e568df34d97c
bcf0bea5bf6d92023e3f8c5a09fe611a2491fdd1
50214 F20110115_AABIOQ mcnally_p_Page_053.pro
177b019c79a6e52fa534369b1cdbcaaa
2a8e8b4609019cd28e532432fdac517726ccdb35
51911 F20110115_AABIPE mcnally_p_Page_067.pro
c95542f2db8779e10cdc4db90b86dcd8
70ce4ee99441c97c4704ad732c71f6577f90f17f
67267 F20110115_AABIPF mcnally_p_Page_068.pro
bb691d253f92a98cef049115e42c068f
e44d623f08dd33ff4d08c1f83a9ae388c12caa2d
36617 F20110115_AABIOR mcnally_p_Page_054.pro
8396104923ac4e6caf60367c95827345
3de12e19748675d7ed6aa164151bc24177ac8478
52049 F20110115_AABIPG mcnally_p_Page_069.pro
ec39ab5fef562c8de631f65e662edf67
ad60d41f47b11a7207a015890ea52d128801913e
41068 F20110115_AABIOS mcnally_p_Page_055.pro
ba1b38220d1431ee9ddb4b0fdb4ac6e5
f7b448afe2c1c0a0382968e8a15fdfb5feb54f46
36635 F20110115_AABIPH mcnally_p_Page_070.pro
7018d6ce08f30f55406172e29c86725f
ffe73ca7886834be1996b4bede37680dd46b3938
49088 F20110115_AABIOT mcnally_p_Page_056.pro
66982dc2146afce7e474285b469e3402
3446b6d15ab6cd7eee10f8f10c4aefa970af4e07
28884 F20110115_AABIPI mcnally_p_Page_071.pro
93ebfff44e2fa440292842b141d54268
1e8a236242121b6d191bbeb3c5e343cc46222bf0
51395 F20110115_AABIOU mcnally_p_Page_057.pro
261b77b73f22011e273b9a0820f22b20
7a63caa9d16367cdbc6cbc3aa1f344c0647b9285
F20110115_AABIPJ mcnally_p_Page_072.pro
7ddfbf8b650966e510677a72b0d98343
3602646ad1fda25a1ddcabb3f47a70d1e3f78dd5
46473 F20110115_AABIOV mcnally_p_Page_058.pro
830792a55f025ef3173ebf2fa879650e
0243928fa72b67e5c1f2206c73dbae32f048ba4c
33687 F20110115_AABIPK mcnally_p_Page_073.pro
68ed2519b6cfbe13d33306b2bec82a27
1c0b72256f9cac420db3d67a95063ebd964e7b7a
51830 F20110115_AABIOW mcnally_p_Page_059.pro
f89f495d10389164d93b61d8ff9749f5
02ea32c329897a27a4a105f5cb81bd55090000bd
65520 F20110115_AABIPL mcnally_p_Page_074.pro
667b7d9d45998380f4f8009867cff9aa
5f595ef5488d29618014ac63873f89eec5ca5e3f
50748 F20110115_AABIOX mcnally_p_Page_060.pro
5a3a488adceda8e1d375dfa79cc7c04f
2bc018c93b2576bd37ad9806fc8f671f947e421b
27351 F20110115_AABIQA mcnally_p_Page_089.pro
d999dbc157b50051a1ab9b08561a5c7e
5e2cb858ec5535c03f8c69515050e53d03d4b8f9
55935 F20110115_AABIPM mcnally_p_Page_075.pro
5c958311cfed29c9d5d3e0b61bfa928d
25377c1b8ecafbbff5b38747d936987655185f32
27899 F20110115_AABIOY mcnally_p_Page_061.pro
7641268c31de46406ceafebe6caaa91c
a1c9a028390d23833251a27ac6cecf9631f87dc5
25831 F20110115_AABIQB mcnally_p_Page_090.pro
9404598c6d2b40bdb77f6be2f91e3a6b
45808018335f787b85630a6e716a37af7f3c8a77
64939 F20110115_AABIPN mcnally_p_Page_076.pro
929cb12a09dfaded769cde360ae27468
79299cdbe53f8df9d6893f4148473b114fd75376
1083 F20110115_AABIOZ mcnally_p_Page_062.pro
8170561dafec490f0e12f19e1f45aa06
bd43ae04bcbc1c3948abc7a69b9972cb4b6aa4f2
18898 F20110115_AABIQC mcnally_p_Page_091.pro
20e82505416559a29388fd9cae41bfbd
fefd84d65dc50faae08dab20ed84c88cd56590cc
52772 F20110115_AABIPO mcnally_p_Page_077.pro
754d055c71fdb399a9b89d034db315d7
c95e57b3a9ea0639d50c558f7c8de202372707a5
26994 F20110115_AABIQD mcnally_p_Page_092.pro
b54bae60d24aed8868f1b4bf981e42f9
05de533df2bf90bdeb7b5d391957393b78679da5
60195 F20110115_AABIPP mcnally_p_Page_078.pro
091e71b21f4c2f24601eac9ab802dfa0
170600a252ffef8dd7e0c5da0f07bbb44a692d1e
21187 F20110115_AABIQE mcnally_p_Page_093.pro
04f1ea5c4c82c489850dc5748a7257da
1b5da54c75b1c9807323d8bac7f742171f4e8ca2
29611 F20110115_AABIPQ mcnally_p_Page_079.pro
b960034a73f2f1e2e66b96f2bae66967
cceb5566990fbdf0c6e0e8a2b7964d11f1fe326e
33788 F20110115_AABIQF mcnally_p_Page_095.pro
b13f7ef8420d2d9f426f7e2f1fb38fda
606a5d003d698223c288582ee170f2ee3e581c87
F20110115_AABIPR mcnally_p_Page_080.pro
b29a390131a9b3031a8232316d2ab2af
d6ac2c29c207b5c9a925677b4cb379574c9887ba
33018 F20110115_AABIQG mcnally_p_Page_096.pro
7ad4d853e18665908e5e64720d675b26
d6e719ed081a41801f29907a5b6cbbd0784449d7
55930 F20110115_AABIQH mcnally_p_Page_097.pro
65c93e38251ad3c1d7631b2365fe5287
53bdd9548aadfe3390564eb5560e66a70c346664
38531 F20110115_AABIPS mcnally_p_Page_081.pro
bdeaf27ffef6fc350cb76a983dcf6998
e31fe719f6a8c0985e9df9e25ae93024c35d2f52
62536 F20110115_AABIQI mcnally_p_Page_098.pro
7f8b18ffd5153b0b24ed41e039fca86e
c2d48d67c46ea5a4dd1cc030dd9271e189268d07
67853 F20110115_AABIPT mcnally_p_Page_082.pro
60d200044998a1a32ea0b0500e15a658
1118c927a9aa93ac8cc223b86750b0a7607b1bc9
60827 F20110115_AABIQJ mcnally_p_Page_099.pro
c0d89f91c9a972ed2888fc3155057b92
b0d3e19fd11f664e1c3fc82bd387f31950411aa1
57044 F20110115_AABIPU mcnally_p_Page_083.pro
8eac216ee34977ba1b394a425063077b
0f384c1799bff1983c9438f3154fd9fa4a83d6e3
65288 F20110115_AABIQK mcnally_p_Page_100.pro
4e08c5a0a50ec2346da275ff96f35575
80e91dd59dd62c5db4ede53e249ae3d20e3a0d09
69142 F20110115_AABIPV mcnally_p_Page_084.pro
1c4eb37f66889de9eee3a570a4a18011
d96c9d3ea662fede76f537d4a355a8aa3fd9f937
42827 F20110115_AABIQL mcnally_p_Page_101.pro
eff7cc8ec791a51ddfeb4c058de6521f
82a39d04a3ef8aebe946a2bbb6d3e3e72a54c2f3
52913 F20110115_AABIPW mcnally_p_Page_085.pro
2616a2589c435c6c67ac5a8104895380
135af0bbadc70fd517961f487a08d87e42d8ad16
1953 F20110115_AABIRA mcnally_p_Page_014.txt
33154a4d070fdf293dd3e60c2a17b2ee
46f14c79ba92817d926aa364759e9060993cf5bb
23152 F20110115_AABIQM mcnally_p_Page_102.pro
581113ce611689fd812fdc4ce1cb4094
c1b8bf33be2d3254b50a71aae830e6cb55d8357d
59570 F20110115_AABIPX mcnally_p_Page_086.pro
ecc5ca733de4298b1df40414a699b3a9
93c1f50becc375a7bfea75d86308563cfc84df14
1944 F20110115_AABIRB mcnally_p_Page_015.txt
b58727e0b767c38a67394264bb95ed2a
fd6a8044868b991c83453e2dfa2194a8aa9e53cf
485 F20110115_AABIQN mcnally_p_Page_001.txt
2a0356cdb6c4def6ae2ab45d1d176216
63d6ef205367a353e83ce64dc94e7b5caf2beb23
29367 F20110115_AABIPY mcnally_p_Page_087.pro
58e1c83f86c8fe8ebb3b370ac647f506
982553006d17ee298a6c37b2b89965ef8cb65e0a
1956 F20110115_AABIRC mcnally_p_Page_016.txt
81e9fe06eae5e41a95fbe503beb6d172
0f94aafa3c4e85ad46555775e7658355dc5eb5ff
118 F20110115_AABIQO mcnally_p_Page_002.txt
1a68340d897f1704d6fe9b6e7c587150
32c28ec585ff54e6ac676408b5a241f59241731b
17720 F20110115_AABIPZ mcnally_p_Page_088.pro
b628396d9b73ba0afb538b4f03d054fd
0733b57485c0b84d76ef1e3dfaf3524c3111f7b3
1984 F20110115_AABIRD mcnally_p_Page_017.txt
d3e8616edc1a7e28cb15e72a5ac5e3f4
3e30ae32720deae1140322690c805d3af3463abd
78 F20110115_AABIQP mcnally_p_Page_003.txt
791e1833fd835bf33981ca070dc6adcc
dbc827e9c33670f44f83164e38e8e0570758af8a
1834 F20110115_AABIRE mcnally_p_Page_019.txt
a9784c7c44e24f5e56702fa142625970
70c6b1bcc431f4f4208936eb7c6c0b26663da3a1
1620 F20110115_AABIQQ mcnally_p_Page_004.txt
5da925dfc063acc257a07ddadab96c3f
63bd7122e3f2416868df108696cc02a42a3aa8e6
1862 F20110115_AABIRF mcnally_p_Page_020.txt
de68cd3db09f40e8f0dc9020c2390f95
96dedb56dbacce545a44e8ffd2bc6189ec087541
3417 F20110115_AABIQR mcnally_p_Page_005.txt
fc739c9e9f7025c07a83c5be559c4d19
61dcc49eacdd5557a2ec218634a4dcc3fd097b86
1783 F20110115_AABIRG mcnally_p_Page_021.txt
55df7eef910052a81c6da43f7c23c77f
9447b62d88759a37ffafce96b399721d9de1da66
3732 F20110115_AABIQS mcnally_p_Page_006.txt
fe7d6694cc8f3a6070f32b8fda7979e1
17859be6cece87c82958da0336e75d0731212fe7
1955 F20110115_AABIRH mcnally_p_Page_022.txt
30114540355edb5a01bf25fb90bf8340
a4a3abc53ee30b6948faf79bfb97ee98622f682e
1907 F20110115_AABIRI mcnally_p_Page_023.txt
282183759bfa8cb1f11c5161d8618f15
8d22c6c8ee1e7f55138b3cbadb5ab90e13b5f531
547 F20110115_AABIQT mcnally_p_Page_007.txt
ddbf19f9ae8a0a7e7a6d81b000b08196
c880d327c63eb9effbb7868ce84ccbe576f6b1a7
1961 F20110115_AABIRJ mcnally_p_Page_024.txt
13e066476bc4cef70a5f49ad833595a8
f3c325409213b3d4471385205c210df83b77cb37
1405 F20110115_AABIQU mcnally_p_Page_008.txt
6512f52a4409950526b8c4bc3bbd26a4
3aefb85b3c935c150f1cd1ec76fecaa9d66aec8f
1968 F20110115_AABIRK mcnally_p_Page_025.txt
235897b0f2345f5a4d982724e16020ca
cd620baa14651e87b7ea9465d22fb0ddd83c6e7c
1640 F20110115_AABIQV mcnally_p_Page_009.txt
3879c41c293c60c1d83b931ff17e7a47
09c52df1b27d1fb0c26f99f73624987ed542f6c7
1915 F20110115_AABIRL mcnally_p_Page_026.txt
2e3511503e455a3ba69bbcceb122488f
1e418d358703579583763d2365215442ad829aab
1854 F20110115_AABIQW mcnally_p_Page_010.txt
3299ddf5ff9fcd0a0a9069c24b0c769f
353a023e4eb1a2d3f975333aa8877889c5262591
2028 F20110115_AABIRM mcnally_p_Page_027.txt
912aa58021a7b07f06c46f42be13daaa
0922e4195b4e25e3b00337bcee25f9c8d958ce91
1758 F20110115_AABIQX mcnally_p_Page_011.txt
5715f560d6c973af7f4ee4b075a8d730
5f5f2d206d62cb9d710eb351adc0d0343c31e0c2
2020 F20110115_AABISA mcnally_p_Page_041.txt
fbc35d52e638bcfd926bb0bff56d5bf1
477dd0b35a16411734c6989bca84616bbc4eecdf
2067 F20110115_AABIRN mcnally_p_Page_028.txt
59066d8a3c70708dc5239a6cf03cbde1
11ab520b0b55db755171e08799c02349679f2ccc
1923 F20110115_AABIQY mcnally_p_Page_012.txt
631f897b324b865f4fa31976fe90586c
2c7540df3ac68e7d32fa74f907c04cd834e83815
494 F20110115_AABISB mcnally_p_Page_042.txt
afa12826e0a1bdc2378f81f281992a7f
c42df452b7dfea0422755230e231fa157698a17b
2049 F20110115_AABIRO mcnally_p_Page_029.txt
c959c827a03e83a22c6a9c90feba2982
3c455e600bfe2d51a19e804a1896fa44d7d3d0d9
1749 F20110115_AABIQZ mcnally_p_Page_013.txt
218ed5aaad40d9e78d8b7409a2284b7c
9ebb990cce0bbc3a9d62ab0d1142875b7dd25c00
1790 F20110115_AABISC mcnally_p_Page_043.txt
a21b8f57349cd8c96e3a45459c335bb3
85e8b1a53c0fd9a1c911d53d4c4feb0c31c4a0b6
2084 F20110115_AABIRP mcnally_p_Page_030.txt
8b042cd9b01702a8b4164a97085ab32d
237b4b03507c2c5edd217ec7117689d079e2e9bc
1696 F20110115_AABISD mcnally_p_Page_044.txt
2292085b362e1e2d8cfd62ca4761ae6d
ab27bb7d66fc48a8d3ec93fb7a82092270c07bc9
1905 F20110115_AABIRQ mcnally_p_Page_031.txt
8b42cfff5fcff5b9b7f12afe36d747f3
8a433f4918843b5a0c621be2301b2c1d99a9ab78
1869 F20110115_AABISE mcnally_p_Page_045.txt
b8b0755e3d253002db22221bfd9f2868
bbf464ce9a7a2823cd58ab9d627b39f9a6bf28dc
1621 F20110115_AABIRR mcnally_p_Page_032.txt
85339ea24ef457a783a9d7e7ecf112b0
c81e661937bf37fdc7dfaa5703db9259f0423e13
1974 F20110115_AABISF mcnally_p_Page_047.txt
edf0f9ad2d3d2f5e43318548ee71cd30
0a8648a319871b25ff8517e02c5a66cc60362b19
2092 F20110115_AABIRS mcnally_p_Page_033.txt
d7b85af3b9a7d5f0b8d41f39a94577dd
182a5347b007c86ee11a08e384c57589838090c0
2250 F20110115_AABISG mcnally_p_Page_048.txt
07ab601c1eb560497ff970b7c2235588
fc9cb77b8a466000de7089119fc82f90c9d6d311
1672 F20110115_AABIRT mcnally_p_Page_034.txt
279da6ccae272a2a14473326ec642a03
800820ae6b544756c8c380c68f2e46506d8db9d4
1289 F20110115_AABISH mcnally_p_Page_050.txt
6de30f2369d9232050cd9ea052097e34
cc25e6a4892abc4238ef319967969cd84be0fe01
2115 F20110115_AABISI mcnally_p_Page_051.txt
0eb4d853a85b965827f809b5b56d2045
749712b3636fb29819a9e9839596371e880f7ae9
1584 F20110115_AABIRU mcnally_p_Page_035.txt
53339fec94416fac4cebd60fd042eb97
a782d4369acb96fa659151dc3007d4129e09f7d1
2193 F20110115_AABISJ mcnally_p_Page_052.txt
2e610e6ffbfa5d4e6e0b755d070cf07e
471a99d2fd229b040faaf861ae0c0804d893e90f
1801 F20110115_AABIRV mcnally_p_Page_036.txt
b2ea418331192f247eaf6bb196ed4a20
69627eaf2374f8d10070d48cbf2b20847ba1b6dc
2394 F20110115_AABISK mcnally_p_Page_053.txt
d0681a178eee5322eb622d52ca6e90cb
0ec8b01f275d81b5e5835630cbcb4a40f999fca8
1899 F20110115_AABIRW mcnally_p_Page_037.txt
a0b87a6ca3cdb0da5a81a435952d1a4e
0f38ce7c5b24d6f19198072e7c82eb28bca7d6a1
1459 F20110115_AABISL mcnally_p_Page_054.txt
ed07437f2841b9815cb4d5597e7fa3d0
95d4f90ed9d7d4f532ebe4097384906671d7a774
1820 F20110115_AABIRX mcnally_p_Page_038.txt
98be13c04a1e1dc2dedcb1159bfef469
256795dc76f23c3873ad5801c5f5c9fdcde190d8
1511 F20110115_AABITA mcnally_p_Page_070.txt
3d86cc87a1ee7167a19bc1ed9478b72e
b6cf8ce5c6e6d6806d185d901790e4e058557ee8
1748 F20110115_AABISM mcnally_p_Page_055.txt
1f813528d9c87bc25f033fee030958f0
173c1ab5563413b9948e8a017ec1a6cd1a2dd19f
1692 F20110115_AABIRY mcnally_p_Page_039.txt
60570012858210af57b0d9b3a7227b53
9dbd4ebebb8339bf78e4905f4d4db2bb492b9798
1240 F20110115_AABITB mcnally_p_Page_071.txt
a82c064cf692078dff23bc4d979d0c8a
a7d1a175a070da65209d10a122bd6084766a18ec
1940 F20110115_AABISN mcnally_p_Page_056.txt
8351655f4a53041c4a8c392f38aac546
a35627f5fdc473f2425fa8158add7e88a1af6d51
1817 F20110115_AABIRZ mcnally_p_Page_040.txt
6e7a21072f8dc0c64459a2ec06aedc2b
c3dbc8cd7be971d00182aa921b87d187b8858d41
89 F20110115_AABITC mcnally_p_Page_072.txt
57e4dc2aa7324973d5ab01c7b5a85818
f4c975ee566167eff87042a66e2541b6850dd561
2019 F20110115_AABISO mcnally_p_Page_057.txt
cdc4dce65c6060959d9e70bcc5d787b2
b002ae00c4fb079a9ebdca203f0b10ba28a966f4
1571 F20110115_AABITD mcnally_p_Page_073.txt
fe450ad8292dc4cbd4326d59e8afc790
5f0b1f50e4e0a6bd48fde279160c08154d7cc6bf
1884 F20110115_AABISP mcnally_p_Page_058.txt
6c3faa30a40705b13d03ad1e1c4f1149
d28f36433c6df72c1e1d042d53a16e5472974778
2736 F20110115_AABITE mcnally_p_Page_074.txt
87f4bfce72a19a55ac7140e77b2e4b57
618890ba5a5d7e95c1aa3ed7518ef5d9e75486fc
2036 F20110115_AABISQ mcnally_p_Page_059.txt
9d011d387412518fd617ddf8effaabb4
5b99f45843a115903b17dd27dfde245ae1fe592a
2283 F20110115_AABITF mcnally_p_Page_075.txt
9eb1b24fe39449495236772679068625
766651768fee621e2abcb40b7de2835875087cd8
2013 F20110115_AABISR mcnally_p_Page_060.txt
e31b1e6aa903e5540fecde05e0212b15
6d3d6fcbb14db1edeb3c02eb1a1cce575a7afab7
2640 F20110115_AABITG mcnally_p_Page_076.txt
688d599bd8d40cf6ef844919caf1b33c
ee665853baeee2bcec5e0048d8d8ad1955df272b
1120 F20110115_AABISS mcnally_p_Page_061.txt
8bdeae7b495a1889e549acc8904dd379
dbf1810deee78e89f8468406e1c6ac4d15f9fea0
2233 F20110115_AABITH mcnally_p_Page_077.txt
1ee82b6ca6c0b0d7423f0d1da2d85bd9
c6232c0cdd9265fe006525f8a5a9b11247226581
65 F20110115_AABIST mcnally_p_Page_062.txt
40c95c9715df6d0cee3652e38771f4c9
4f2d6c543b8071889265ccd7292e0dc80ae78bba
2478 F20110115_AABITI mcnally_p_Page_078.txt
b83b2e975a7a9d4b109041c8378a844e
746a8e9af933d47f69665b334fdaf237d2b84040
F20110115_AABISU mcnally_p_Page_063.txt
92dded55d3e272cb851e7fb80247e5fa
441a48d70c633720ad2e3d2719e644cb515607ea
1202 F20110115_AABITJ mcnally_p_Page_079.txt
bccb19243b51419614feb9ea6360e4fc
d78833d3d444112c77275e455a0c0981a2d21e5f
1616 F20110115_AABITK mcnally_p_Page_081.txt
099ec1f04916ac2f913eb4013adf898d
d4f6ade8783b37c726f93fa455e33397dc7ff131
F20110115_AABISV mcnally_p_Page_064.txt
aa1297b053394c7c84c4efd4b342a626
59642c87c12ff5f157f867bb017e86100f19fe70
2716 F20110115_AABITL mcnally_p_Page_082.txt
b72a2786b3f34688c66a00dc0fa8a07a
babebb8eb1e5b9bba6ec55ae69f4a65d3343b452
2781 F20110115_AABISW mcnally_p_Page_066.txt
a19fcce7bdeb4ae35d57e19b79a066c3
00807a057052e39545883b14169b50d1a33c22c8
2349 F20110115_AABITM mcnally_p_Page_083.txt
81106fcc90b6f4e5293009afdd562a45
be6463605aed25917f405f7202cf8e27431b642e
2213 F20110115_AABISX mcnally_p_Page_067.txt
f896a336898bf49e9c8afbf46e5aa1c5
6a15c9a13ad89141ffcf77ae67d4f9ec53a81190
2463 F20110115_AABIUA mcnally_p_Page_099.txt
71437fbd740857eabaab3a18226ff1d8
29cdba895329a44206fd8da827fbb764d49e027a
2822 F20110115_AABITN mcnally_p_Page_084.txt
ae85a22c04f1665b59dc20f40a764239
91e521345a50b066af67ae455d3178624b9f5d07
2831 F20110115_AABISY mcnally_p_Page_068.txt
5fa5b80da8be8bc63d73ef14e749563d
d0e7fae13b032709b7637c1a222d50b7761bee76
F20110115_AABIUB mcnally_p_Page_100.txt
dd51b51a866ad853fd434dd08a5352e3
05a7bfe33a7f4325ba0e5681989054793ad1f87c
2207 F20110115_AABITO mcnally_p_Page_085.txt
4050f4562c1de3174456037f07537583
3fae1e3438fe1dcb4c14d9d71f2c4638dd0fd55b
2188 F20110115_AABISZ mcnally_p_Page_069.txt
68475bd6a13ae14025363cc8bdc97040
86ff5f4d90d1c83302641069cea4bbd8a47f2fe6
6126359 F20110115_AABIUC mcnally_p.pdf
3eac4e801ea70766fd619360080bfee7
b063f3815854354e820bda655458893c911ac218
2416 F20110115_AABITP mcnally_p_Page_086.txt
60bfe10b32c80af9936e389ff0b64284
fd8a8083291f079fc50437e44c6d3b69a25d344f
69055 F20110115_AABIUD mcnally_p_Page_071.QC.jpg
5b6e15f3201f8561d231010a404f81b9
fdddf90644680411521c6942c6b2648b4e270936
1253 F20110115_AABITQ mcnally_p_Page_087.txt
2e0f169386e3a1acfe886a612b2e116b
f12d375292d8c4ddbc3ee14eefb793f80421d76c
20559 F20110115_AABIUE mcnally_p_Page_042.QC.jpg
88d4487ed23ade8504fa4f9cee58c176
8cd9bc71dd89c418c8d8e803fb861c423cb96f68
1563 F20110115_AABITR mcnally_p_Page_089.txt
86f57539067b221ca60211270495d65c
13d5c381d8ee79a2d8c50d8cf5038e142990f5b8
39666 F20110115_AABJAA mcnally_p_Page_073thm.jpg
ed2d9cedb22f16099548671d88c607cd
144d67319914d6d6f9c7f5021627eb553a1d10da
3136 F20110115_AABIUF mcnally_p_Page_072thm.jpg
61aebded1be17653a392fe10fe379949
fefee7195a60e042472de50ab03fdb4209dc1aee
1282 F20110115_AABITS mcnally_p_Page_090.txt
1a38e33261ef2368e5ddaf78aefb790d
49219797226549bd8e24dab6b4df6b61403e5b72
72696 F20110115_AABJAB mcnally_p_Page_073.QC.jpg
2fec893782cefc46be60e2f612301572
92851ffceca2517bf1cbe147527fb9dfe131a1d3
19172 F20110115_AABIUG mcnally_p_Page_009thm.jpg
4f446673b573be4541e516e44531f54e
1151ed4ab3d3129e1560ade77f7da834a89ca1fa
1505 F20110115_AABITT mcnally_p_Page_092.txt
3706cdcf69c1eb5faee06e951e3af849
639160782cc81a4d3038e6199b2e8eaad9f074f5
6009 F20110115_AABIUH mcnally_p_Page_002.QC.jpg
54884bfb466fc14355d9ce572c826643
96c33352d7fe6befdedad41503dfc4ef32bb0d9b
1153 F20110115_AABITU mcnally_p_Page_093.txt
10413b78b39b74184c2eab035f77e644
ba248a74a5abd6c766143e3e65d538e3bc3e97ad
42795 F20110115_AABJAC mcnally_p_Page_075thm.jpg
99ecbebb277f5c06c4ef4dd2e97acfdf
e72378b46bdd8b01821044452c746814218b0f24
24076 F20110115_AABIUI mcnally_p_Page_046thm.jpg
9fd3b9221030ba8726f5edb6500a10f7
b3a4d8aa146402119140895d35d691e64ba5b019
1776 F20110115_AABITV mcnally_p_Page_094.txt
4d2761f0313ee618cf47da48989d263e
8f28aa20c277a02de34c11a6bb862d41f8a0355d
42496 F20110115_AABJAD mcnally_p_Page_076thm.jpg
fdaf19b7685b86e9fbff925629fb0dd1
4d98b3da2bb4546f3fc219f25bf03b5e3fc3134d
23532 F20110115_AABIUJ mcnally_p_Page_047thm.jpg
fbf02c359f23fe9edf29bde5c14c0d7b
14edf96d0fd71072b83b10d05d022ae46adf761c
79465 F20110115_AABJAE mcnally_p_Page_077.QC.jpg
40a218b8306882bd641be2a4521c59bc
e733c4f1703acdd7f18cedf71061d299e97d9c5d
80787 F20110115_AABIUK mcnally_p_Page_027.QC.jpg
be5de9dd66cc7445f48055eaddb3aba5
12fd3b4e54b3c62d63156c6a9bfd01b6da718125
1691 F20110115_AABITW mcnally_p_Page_095.txt
2b0009460d68fbfcff46f7402c9ba39a
b380962851fc0789bf4e8d925d7fcb67f78838c5
43019 F20110115_AABJAF mcnally_p_Page_078thm.jpg
f47bdeae56ae8085eb67aa1cc6677838
24907f52ec357b72f1141c64418bd3615a8b7ac1
85735 F20110115_AABIUL mcnally_p_Page_074.QC.jpg
52c0eecf9296fbdedf75d89e4a195c5b
57d5a803a464955d83649dd8964db315ccc92824
1586 F20110115_AABITX mcnally_p_Page_096.txt
0125059ac91aa7e85ccb84d38c7801dd
091082fbb84b1151497deae1ca7bd9fc4d722d8b
84175 F20110115_AABJAG mcnally_p_Page_078.QC.jpg
026a989ebd1a31f5d33ad676e87fa71e
2ed84c6fbcdf15352cb741d075a7b502970bf8b7
42229 F20110115_AABIVA mcnally_p_Page_074thm.jpg
dfc186b47818a4c528a44f181273bd77
0489cf60544ef8b3c70080265260e2886b2f2657
42765 F20110115_AABIUM mcnally_p_Page_067thm.jpg
8b403a2152bb351a70f1e354e9d2d4d8
bbc6dbfbcae611336fdc21393be44046311c2344
2258 F20110115_AABITY mcnally_p_Page_097.txt
ac0507f402163aa72cb370ebb682f763
aa11bc20e7e772055559b555b5c3264cc0532480
6833 F20110115_AABJAH mcnally_p_Page_080.QC.jpg
470e0c6d02d0d5e3076bb2f2a81fc1be
6fab2d34fa5d51fe13b686c2eae72211ca3144c4
8032 F20110115_AABIVB mcnally_p_Page_001thm.jpg
ca4b69591894370a99c7bec855fabf9f
a99aa3ad782e4a1ec448101d0d27b667cbe3bc31
106414 F20110115_AABIUN mcnally_p_Page_006.QC.jpg
99e6bf2c639c53ae7c5788565c131cb7
351a029e2c42439ad0a186c36d7009e17171f8e2
2522 F20110115_AABITZ mcnally_p_Page_098.txt
257dd0ab537dfcb5892354e65ee0523b
b68cf0a7e831cfc52bd166cb498c2f35d1841628
40221 F20110115_AABJAI mcnally_p_Page_081thm.jpg
349bb66d6619fa3fd82ff20aaaf48f5b
c7d02a83d3a12af14014990d17c28e7a10c05152
77097 F20110115_AABIVC mcnally_p_Page_037.QC.jpg
07f887aad775f73f7e01c6bfd0bbf77f
6e2c2ced8fc646bc21d0a01002c1f561f76155fc
24263 F20110115_AABIUO mcnally_p_Page_060thm.jpg
c24824a0d4d1db5652817189cb8cb5e6
3767390a7146d0ca49f52c0d1807a6079f3f44ef
75351 F20110115_AABJAJ mcnally_p_Page_081.QC.jpg
0f5cc4734fb82e0c9a5c52b8544a715d
ba8e030ebf2cd37b220d0274a1b9e8aa93a9999a
17863 F20110115_AABIVD mcnally_p_Page_049thm.jpg
726400fb34ec1f9653465e41f12a17ab
23230310427a54594dcd7383b1a19eb39c540a30
68556 F20110115_AABIUP mcnally_p_Page_079.QC.jpg
336b9c1db2dea31ff19ebfa7c4e3dd23
fa1b66de21ae7c7359a1e94b57dc63d3c15423d8
42637 F20110115_AABJAK mcnally_p_Page_082thm.jpg
197c81d172bf636283ef5fce7c58ede8
528b386950a3f28f1691249b221bee7e0196d721
41337 F20110115_AABIVE mcnally_p_Page_077thm.jpg
17975dcb97a05c31398b5e6e72ad08c2
5409662d2241bec24c4ec611d75c5c8ef44fdb34
45770 F20110115_AABIUQ mcnally_p_Page_061.QC.jpg
a185db69806ca73ffd1f0d2498a4017f
d5f97d058d47d6b01935feebb3dd6309a5d97f75
43601 F20110115_AABJAL mcnally_p_Page_084thm.jpg
553e78460acfd6985f9acde21d656c83
ba2c15c0260a41c3f1d636860332b8d162cea80b
3137 F20110115_AABIVF mcnally_p_Page_064thm.jpg
1e0514f1d2046b55aecb40fc98da7039
69da00dc5dbe2ddd751125659017256115438e2c
63206 F20110115_AABIUR mcnally_p_Page_090.QC.jpg
598c141a53a265d5221c02bb04048cab
048065dbafd1143eb3f3321e6115f1ddd0b8ba8b
60108 F20110115_AABJBA mcnally_p_Page_093.QC.jpg
ad9639e11309c8335b3e3609815dbc2e
f3dae920e6647cbb0f434f0ce69aca6ac0c17250
89847 F20110115_AABJAM mcnally_p_Page_084.QC.jpg
46fb8401857f65ab9982bfcf9fab5f03
1ed71c439791115e1dd53e4b8d61abf7e0a97c85
20423 F20110115_AABIVG mcnally_p_Page_043thm.jpg
2cd5af685c256f98943ba710e39361bd
fcaea3f25c0f51f6529ad947417e90284acf0a6f
40842 F20110115_AABIUS mcnally_p_Page_065thm.jpg
4d067cb563b10376976de2d41797177b
4696a30cb83a8450de1222eada2512dd9e80e8d0
41980 F20110115_AABJBB mcnally_p_Page_095thm.jpg
ad5905be297315d2534f6651209d2712
b561ce83dfe37adf54d0bf27a2d25279881cee4e
42369 F20110115_AABJAN mcnally_p_Page_085thm.jpg
51f9ce13465e54e7979bccbacae891da
9b91f8de241360c6a0df20cb6a5c65397d73a77d
43527 F20110115_AABIVH mcnally_p_Page_068thm.jpg
0ca289e8f232da14cd60622b514cbb44
732afdca74486a87a43daecaf53aa81a9ceeea67
23024 F20110115_AABIUT mcnally_p_Page_021thm.jpg
137a7b3436bc75a638167ffb83136afa
5eecc78c740aad87327a42c813dc94260a050d08
77470 F20110115_AABJBC mcnally_p_Page_096.QC.jpg
4c3bce3f19c3d42da66c863e41e1e3c3
e64bb75ea8476cd098b5152ee8a656d0d3576385
81449 F20110115_AABJAO mcnally_p_Page_085.QC.jpg
d3ea5dbf116b741b998164d77a7fc16d
7b3b16682f3926b14b16e2b17d18018a1d9b15c1
75040 F20110115_AABIVI mcnally_p_Page_094.QC.jpg
0238431e2c2109eb0c10d637c55110c3
823da860240f3f948d09393e5a2e004a25322336
59453 F20110115_AABIUU mcnally_p_Page_009.QC.jpg
e296c7fa3c91ef3d780d1c30a1eedc44
5268a7b322cfefaaec0bccf668dad6b9e203a161
43454 F20110115_AABJAP mcnally_p_Page_086thm.jpg
8df56855ec0121248bc605a770d225a6
59fb8e35fdba1d41c8c495139ff645593f837cd1
38361 F20110115_AABIVJ mcnally_p_Page_088thm.jpg
0199185de17ee194950fb63c73d3bf7a
92d82a95812fd58438f9a6e57dc4fb155402a3ba
21807 F20110115_AABIUV mcnally_p_Page_036thm.jpg
158acf23f396a80a2c6872874dd59673
f75221827e68a245665ad8c16320958674a52dd3
22984 F20110115_AABJBD mcnally_p_Page_097thm.jpg
c44501ff4549ecc6a88062c23c0202db
d2ac66ab3ec58a9dae79c5b8d5bc2ae745af8c13
87441 F20110115_AABJAQ mcnally_p_Page_086.QC.jpg
5662811fb579980e957c435dd15bb34d
60ca64e98edee91fadc1322315b82a026ea072d7
86384 F20110115_AABIVK mcnally_p_Page_082.QC.jpg
4161141578091007e01a127b6d90f95e
115b8767e1b19d4f774f7d971c187d6060e9f951
34534 F20110115_AABIUW mcnally_p_Page_048.QC.jpg
1da0e6b8e43f5cc08a3e8d13cbfe3722
e6ab513ed9636c8b35942391348b4b4bfffaabb8
24022 F20110115_AABJBE mcnally_p_Page_099thm.jpg
88ef1c0fb6d0a53ce2a596d479dcb733
ba991aa3ff89aec31780f58ab2c6d578e5170277
37983 F20110115_AABJAR mcnally_p_Page_087thm.jpg
cfc976398ece92beb2e188c67297a551
b7f3c010d8f6119dfebb87be3c4f482401432dde
38910 F20110115_AABIVL mcnally_p_Page_071thm.jpg
e6583b90cab76281761a233e22c3b281
6bcb949da99c97b2f9dba60d749e477291de91e5
80866 F20110115_AABJBF mcnally_p_Page_099.QC.jpg
8f636c53d87a5f921a4a2d70957d5c3b
dbb9f6694702cb90e99f39e3bd623eb4c391c2d9
6825 F20110115_AABIWA mcnally_p_Page_064.QC.jpg
a01b74cdfdc49b8ebd70237c509ce1af
2ecba4d9ad587787ecb3a60b4de2a297307208e2
66890 F20110115_AABJAS mcnally_p_Page_087.QC.jpg
d9d14fa25fc4c8bc05e1cadedd49f9cb
e64d077827c3ef1206206838b82fbeac6e8652a3
39659 F20110115_AABIVM mcnally_p_Page_008thm.jpg
3eba3547bd8ce147838e16b5e5648186
b160c701822a5dd7e2b5b2886d7d84f5270436a6
75454 F20110115_AABIUX mcnally_p_Page_070.QC.jpg
3c38b1caa9a5e6c73da3a3e4ee2c2fb9
8dce02b1e803767dd8a0a08d9e25f86263b44e10
25236 F20110115_AABJBG mcnally_p_Page_100thm.jpg
125cb45146cb95b32503cb4af5d78496
e1415f8062a476970488a1a9557b6d1f0681eb43
85079 F20110115_AABIWB mcnally_p_Page_075.QC.jpg
3a1ff24b8c5c070e0529d188a0eec3bc
31e704bdb1b5f5af09c5911a3c35b07bc7334301
65687 F20110115_AABJAT mcnally_p_Page_088.QC.jpg
f9c382765c27c0da41043827678967a3
ca9165333df95252b20cef6e150ef27e7e52ec05
22920 F20110115_AABIVN mcnally_p_Page_031thm.jpg
3d4934cc2319f462c8039fb85cc34718
28ffe6ba07da11755ba8925eb4cb37e823ca2710
48945 F20110115_AABIUY mcnally_p_Page_006thm.jpg
59ee04ccef03882994154f395921ebe2
805e9a9a2a57461fe8daf8d2ec3974b9caa1c448
20035 F20110115_AABJBH mcnally_p_Page_101thm.jpg
bc8d848d5185e3d56b34ebae576eaf0f
82dfccb2a5b1e12ae99499dfb01cad919cd696d9
23336 F20110115_AABIWC mcnally_p_Page_023thm.jpg
3ad3ada06b517d2a3130bb681a8c1e3a
218899e72e6b8c24297e9c10e5d83fb922ea2d7b
37546 F20110115_AABJAU mcnally_p_Page_089thm.jpg
814f4b8b272c37273e32ca83a87e55de
0b61d6ab0dcf90056022aacda20063a7f8be8fcb
36072 F20110115_AABIVO mcnally_p_Page_050.QC.jpg
08132d4ff6543193fbfab4b4b239928f
9f555d548724f95b6d2862ad7688206bb19b4f06
88862 F20110115_AABIUZ mcnally_p_Page_100.QC.jpg
32f0f5c55d130ad9c939e9dc48652f0c
6cd24f8ff2affc6c1042f1a2a06d28bfd609785a
61830 F20110115_AABJBI mcnally_p_Page_101.QC.jpg
ac8c0dd52e01f1f4158f23ced3a47ff1
eaf72335767fc443c3d124a57ca26225aa153364
76956 F20110115_AABIWD mcnally_p_Page_097.QC.jpg
7c684aedfd9e873e21bc0304d9a4d892
d8a195c274e174aca9262138628af2aa9a160b06
63494 F20110115_AABJAV mcnally_p_Page_089.QC.jpg
6f284dad8ba13f7718cb24428e990824
7f972bc3c161da7835b64344d27c293a7f26de2b
23494 F20110115_AABIVP mcnally_p_Page_016thm.jpg
0cc97ecd8bc431bc45294176996082f8
4b09de95aa17fa021d26ddef8c3d411b5b017700
40131 F20110115_AABJBJ mcnally_p_Page_102.QC.jpg
920a097f59097b31f055ea2b455b5212
699e003b1e8ea833e81e61b4eae4f9347a8000f1
83376 F20110115_AABIWE mcnally_p_Page_069.QC.jpg
fa2c15e33f1b2aaf8f89c86d94cad201
76ba27376ddde09ef05c45dd266f42f8ef0ed126
36465 F20110115_AABJAW mcnally_p_Page_090thm.jpg
42d9b028ccc6a8cc54ed0ac63cc282ab
e1c7ab52850ecee0ff32e6c1fcdf5d4554e14049
23555 F20110115_AABIVQ mcnally_p_Page_037thm.jpg
a16cd28a7f5a9e3b0a8e901d5b16f8fa
d4c31c534df76a5a9224fafaf751145a70e92a18
64745 F20110115_AABIWF mcnally_p_Page_011.QC.jpg
e5c0e2537764c03972b422eeee93a3ed
d152fa522f4aba7dba8046f1b5f62c3134735539
59363 F20110115_AABJAX mcnally_p_Page_091.QC.jpg
a987f0c55528551aa3fe02953ea61738
e2387aa0f13f3c405a2aad4f4d6fb86c97651f6c
13471 F20110115_AABIVR mcnally_p_Page_102thm.jpg
0ba6cdf71fc92423194cc0b1dad9fb6c
a7832fb158b05155a5a48702f65a839842e7de95
73847 F20110115_AABIWG mcnally_p_Page_008.QC.jpg
4246390260c08407d5b89dcbc7eaa2c1
7ea0f5aeaae0149de927672e4f150b7042c61f9a
63632 F20110115_AABJAY mcnally_p_Page_092.QC.jpg
4445210be57ceabf9385c51925f43808
401ca5ffecfbd726b8d5f9c8c8c59ef96b40307a
41044 F20110115_AABIVS mcnally_p_Page_094thm.jpg
2e15a276b7932ce796f84767ec49912d
bd5414497391b0e420a754656a939ba4fb45d383
80801 F20110115_AABIWH mcnally_p_Page_029.QC.jpg
36cce35661003ef7fe6501daff91dbe9
0d132da51dfab7fd9212eb21ee137b4995aec429
36195 F20110115_AABJAZ mcnally_p_Page_093thm.jpg
593625500b30ad9cc4fdc9c544c1095c
5023420a01d4921cf0958fbbbd760c4013954fca
21397 F20110115_AABIVT mcnally_p_Page_011thm.jpg
0f5e65bcf92b21c5ccb5ab368bc31954
d12f452b5d6aea89303a1673a24a0e2955f40951
84073 F20110115_AABIWI mcnally_p_Page_076.QC.jpg
2e046b5e5a9db6bc233fbc15079c1cec
e158142d2439c9afeb54d4c9b9c6c3b79823a516
37976 F20110115_AABIVU mcnally_p_Page_092thm.jpg
05cecdd88d075d9cbde6b23d81f04c8f
914833cbaa47cd62524a179984c830537b4afa53
72153 F20110115_AABIWJ mcnally_p_Page_058.QC.jpg
63d8025c63ba9d19cb5ce415e188f5c4
344f7d69aed2ceabd7a6fa84d0c159db83e968f6
38312 F20110115_AABIVV mcnally_p_Page_079thm.jpg
8b253c50ad9a192209f3714282f0135b
42da60a71571e2678252fff5cfce397aacbf4e58
42316 F20110115_AABIWK mcnally_p_Page_083thm.jpg
02919a53a568b478742e343b92325c6e
274cd72f5c75deafa642277b79986c53f152dc34
25402 F20110115_AABIVW mcnally_p_Page_057thm.jpg
68e1a81aa57c6dc358ba12d18e3b60c5
b9c5d48ffa9a6449fe0505cf054fe76dfdb452d8
74786 F20110115_AABIWL mcnally_p_Page_023.QC.jpg
3eb5bcd3f90c1e4e83c2d8a18fb603f7
4143b7ab9913f4d246368c82c47d8da4956baf4a
90507 F20110115_AABIVX mcnally_p_Page_068.QC.jpg
07d8774afcd8c5630764c68c5a6601b2
81f16860902fee951168477f2312eb054331dee2
78723 F20110115_AABIWM mcnally_p_Page_012.QC.jpg
9a9d9eabab16a62dc35e14b82c48bc78
74870efb50cdd0f07484521436407bc9c011f322
43102 F20110115_AABIXA mcnally_p_Page_066thm.jpg
dcc90b6243f402166258abe9478e7a82
7a7f5f4503b33d15906563801d80a30a099777c1
73037 F20110115_AABIWN mcnally_p_Page_017.QC.jpg
726392bd56919255cceb8ad572382b43
709fe70300b06b6e2f8e5477060edbd34b87b77e
24608 F20110115_AABIVY mcnally_p_Page_041thm.jpg
46694da1b3bca8308b19fdf5c853fea8
fb5af07e95cb5e52d002f95913d75a4aeb90461b
25119 F20110115_AABIXB mcnally_p_Page_098thm.jpg
4dc7027358ae2c5544adfde9bd00b3c5
df4d452e525aa12a722f38adb8b4f480a0ea30af
12290 F20110115_AABIWO mcnally_p_Page_050thm.jpg
365b40175667e021727ca3d6187293bd
c546a2f66c63997ab6818ffdc15ea2778b2b8b71
40345 F20110115_AABIVZ mcnally_p_Page_070thm.jpg
16a8662401fc3bbe49bd24d429691910
a0cdac231af472cf4f0d9d5df95c8dd5102f9314
38450 F20110115_AABIXC mcnally_p_Page_063thm.jpg
6e5748a8667342017f8c6336347d50c6
59c0c99ff823a9668c25cf88da2bcd0e7dc8e4b2
70432 F20110115_AABIWP mcnally_p_Page_038.QC.jpg
2eba7342436e54b342683194f22dcd05
0bc4b905c04c185372ebcff0199eb3f1a0f9f856
24005 F20110115_AABIXD mcnally_p_Page_038thm.jpg
5bd0948b74e34d12bf5d01ffc4bc883c
3239cdb2cbfbd1d2862c8fe32d3136990cf83a2a
43491 F20110115_AABIWQ mcnally_p_Page_069thm.jpg
ec5098235dec76876026546387c685cd
545d7737be338041ff352fe2b2ee4d1cdf832db0
154618 F20110115_AABIXE UFE0008386_00001.xml FULL
9b6bc62d1356aa021c51ad4bac51e539
ac90fc8dd588834caa41761fd7260bd85febcab4
4444 F20110115_AABIWR mcnally_p_Page_003.QC.jpg
40e7718a4a671aec22a986d959e06bc8
f4f97ac6d8916c5efed4ff986da29bd8ae774001
21530 F20110115_AABIXF mcnally_p_Page_001.QC.jpg
f06f2feddf21d5ff5388411dc3132449
f2f28c56f1dba703549ab3bae25287e5527474ec
63576 F20110115_AABIWS mcnally_p_Page_052.QC.jpg
fab7c637e663e1c5673ee6ed28b130b9
535223654ab36df2abbcb5410e6309f6b6ff8f58
3190 F20110115_AABIXG mcnally_p_Page_002thm.jpg
2d231bf6d2fb5742ea20b9d3bfee7ab3
952e661f9183e2d60e197d5f5ac8e9a8245212bd
21511 F20110115_AABIWT mcnally_p_Page_039thm.jpg
4928bb4abbb213eb3fc3ce141462471a
9c94da7502f5200ebfaab896535b225ba1520d24
1952 F20110115_AABIAA mcnally_p_Page_046.txt
3cc2b4fc2c1ee74d7273d62a3d691c59
20d0c15b3a83fb5a5e76e990b2a2bc8a2e94f03c
20433 F20110115_AABIXH mcnally_p_Page_004thm.jpg
c96b3e9be3ae3ebc46bc52fd5fcfee67
97341277ba62c6caad5bc09f0f900571616868d2
64411 F20110115_AABIWU mcnally_p_Page_051.QC.jpg
a5c14b3cd40c20a69367669e07323209
3cfc6ec742dd946480fc610c72624a9bd16fdb29
973 F20110115_AABIAB mcnally_p_Page_102.txt
df75c05ccee400fc2034d96f571079d3
4aa8619b44a3a5f7e20c3ef5e12d2d155211d63d
64819 F20110115_AABIXI mcnally_p_Page_004.QC.jpg
a90ed1501dd14be1b1f751e90da0134c
5c2134c608ee2e6458653a5bd13d2ff5c352ccab
5780 F20110115_AABIWV mcnally_p_Page_062.QC.jpg
b0061d1997561fd2350c8c1ff1e7cebd
32e34dd0e1e37a33c8df5844b28cf05782c23d0a
968 F20110115_AABIAC mcnally_p_Page_088.txt
ac2c0cab5db5ebe48e0eaeeb7d320f8d
d7aff97b5fc3d7a840e87dd9b6835c1a319100d7
46328 F20110115_AABIXJ mcnally_p_Page_005thm.jpg
deff0e5e4371e00447fac964f777ae88
a923566bd6f51634f48fc58ad0eafba6f5ad281c
84339 F20110115_AABIWW mcnally_p_Page_098.QC.jpg
088faa1e6b1af8ae4046a813aad9c3fb
3d15c089231d58429b9de29a24111ae9bf2c476b
95269 F20110115_AABIXK mcnally_p_Page_005.QC.jpg
9ce80984b71547f69b0929d22553ef81
bcfd677120c74cc8b14ecc46341f073590f4f456
40908 F20110115_AABIWX mcnally_p_Page_096thm.jpg
69918776d1d5d4fb58c6b34dedf89e62
e5a4f6d2dc741de59eb35e73165d43b00e720efa
63643 F20110115_AABIAD mcnally_p_Page_044.QC.jpg
6b7dc3df1a793297955ffb1d210e4b00
2c87be1a6211e385e5842c1ad9384eb253f595ac
46208 F20110115_AABIXL mcnally_p_Page_007.QC.jpg
9cc3d8181e6a89e9af93bf5baa7ed99e
5ce735d7aa99d9ec5b785c21331061b9d37f665e
70584 F20110115_AABIAE mcnally_p_Page_045.QC.jpg
7d02fa940396af2fd3784f785140ef8b
fcae33e976dbbce569831dea0bb7c46d44a52c72
69867 F20110115_AABIYA mcnally_p_Page_021.QC.jpg
52bca072fb64a8fb31bc3e858221118f
436e8461ff02afe33c2c856ecd26be39d3d39ac9
23169 F20110115_AABIXM mcnally_p_Page_010thm.jpg
7e9487bf144cc5d93fd517356b524cb3
de5794f6c3dc8998214c356204478a5a834453e3
23487 F20110115_AABIWY mcnally_p_Page_015thm.jpg
6392af6d838d6860010d73b01aff5b89
eef8602683e1dc281c0b09f1ff216353510d6036
35699 F20110115_AABIAF mcnally_p_Page_091thm.jpg
11f6c9d7ee47ba0315d64fd1b01bb13b
9dfb56d1dc42500761fc5b584fdbb5541f282d0a
25111 F20110115_AABIYB mcnally_p_Page_022thm.jpg
1193ab013e7a6be4e3a74ab41e8e690d
13f1d7b5b208000358b06dbc0f92e84263d0ec1b
72936 F20110115_AABIXN mcnally_p_Page_010.QC.jpg
588a5bbd235496c861b4786f786d97eb
c916a8b8c10ef2c8434137bfd32a9494fc0c3e45
1561 F20110115_AABIAG mcnally_p_Page_065.txt
ff34a222db0b458fa6c1c202aad0276c
e2dedbe9a65725b16c0212deeddb4bb70025ed7f
77273 F20110115_AABIYC mcnally_p_Page_022.QC.jpg
cf97bfcf637bb6a1f84c477f783fafbd
c75fe0b9d7c6f6c56ec9c133cb1b498a0ca807ff
24362 F20110115_AABIXO mcnally_p_Page_012thm.jpg
13eab455119579c433d2deee707b908f
d59c044317a9e22eaa42f42f9b7a80ed3bfb2313
73255 F20110115_AABIWZ mcnally_p_Page_026.QC.jpg
c82df2b51c144d43071870174194516f
9022894af43d5b4bc667d22c2abbb98a82459e35
80607 F20110115_AABIAH mcnally_p_Page_041.QC.jpg
731ead99c3fa985c05646be322395605
ff83362c80fa9a92492dc7bce04b56d27ac34226
23638 F20110115_AABIYD mcnally_p_Page_024thm.jpg
43d51022acf3dbc5c2391aa25b577927
25e4c6f2932c65393bef0e597b00c3a19f405d30
23022 F20110115_AABIXP mcnally_p_Page_013thm.jpg
eb234cf2550b088d61e3221c597d065d
4084cbdd433c7ca724d047195d299aae30fbe6e1
172264 F20110115_AABIAI mcnally_p_Page_055.jpg
0af18501a66fa28d2b3613fe158d37a7
acc8b2832df724a065d8c4006f4344bb23ed75db
76740 F20110115_AABIYE mcnally_p_Page_024.QC.jpg
4a910db4933887ceab6ad288022093a6
f63b5f5022288abb2b6b1cd5d332b4c8c7ab7c3e
68889 F20110115_AABIXQ mcnally_p_Page_013.QC.jpg
073d640570ed0da4a8b79a0b83769651
d04cc711cfd9a8aad0debf586249ceff6fc8ca42
809005 F20110115_AABIAJ mcnally_p_Page_081.jp2
e1f35c9c736952980245f3fd68185372
28b0ca18a5c9c6f47f43473ad187678330dd90f7
76487 F20110115_AABIYF mcnally_p_Page_025.QC.jpg
37b49ca74d417b39431e9d9af46f72e1
0c8f4ff6817b75a75acb4a42a8b884bcc6efdc54
23849 F20110115_AABIXR mcnally_p_Page_014thm.jpg
f2e8c6c68a4d012ea1b767b2e362c780
0c5e518c71f6c9f87433a76cdc002714fe83f22c
24044 F20110115_AABIYG mcnally_p_Page_026thm.jpg
b54b929197c451e5760436321d8b87c3
091f21be9bb9f84e717d2379c690d174162a8b28
75706 F20110115_AABIXS mcnally_p_Page_015.QC.jpg
4bb20ce4102eb34512a3eba4f4781e3b
6d8bbc3c09515d87dcb681eb43fba68bfe4a8715
23310 F20110115_AABIAK mcnally_p_Page_040thm.jpg
aeab793559ff972e55169f30434f1879
526e1b1002b6b213c594734ee7b16412aeff979a
24863 F20110115_AABIYH mcnally_p_Page_027thm.jpg
6e480dd361c7eca499a8427479d44479
3c8e35f11362029dd83e4e42589e21d94ccbec20
23063 F20110115_AABIXT mcnally_p_Page_017thm.jpg
53a278013e16285f2b350bc1dd5720ab
4894af61d456ff571a22da0eff8146a95f27444e
3134 F20110115_AABIBA mcnally_p_Page_080thm.jpg
837ddc877575ab1a782fb0e397b1280b
e321d5aad031a402ed87ad2697279245cc705eb7
170115 F20110115_AABIAL mcnally_p_Page_094.jpg
10c1136a51a2ace21d3e32c7f60591c0
81ed8743d64b98f1eae7aae4cb229c836349f3b9
25392 F20110115_AABIYI mcnally_p_Page_028thm.jpg
40567e49a7f405ed872b8b96772d9082
43dc25153fb761c18ae265d759c81704b4d7d1d0
19935 F20110115_AABIXU mcnally_p_Page_018thm.jpg
aa693413a768190b9cdf0372a01d561d
73a8fc32996020a995f3c361c2d8b99e97d9b7d6
2573 F20110115_AABIBB mcnally_p_Page_003thm.jpg
83536712d738f9e5a8f2d67d54579d98
40f141faf75244292447f791a8aa6764924b471b
5825 F20110115_AABIAM mcnally_p_Page_002.jp2
895f970ea7f4a8cf50538631fedb9ef7
d8a86f32fbfa383b2085517f82924479920f4110
81061 F20110115_AABIYJ mcnally_p_Page_028.QC.jpg
d11206e3499a71333c6a600723ecc28f
91ec75162640a052ae5eae1dd0b6369baa942048
66942 F20110115_AABIXV mcnally_p_Page_018.QC.jpg
9ff60b28ea318092396c16c3243ddc93
42e1ab2bb5620827c0e3f9d6e963470b0f7ce9e0
62779 F20110115_AABIBC mcnally_p_Page_055.QC.jpg
b0f6b5b8f962db453833d29d6cebf5e8
b45c544905da6fb8ae22e05438973caf7d905e5a
91735 F20110115_AABIAN mcnally_p_Page_044.jp2
f0fe20faa6e22f95030ccc6f40949ef3
a3f864bbd201c2c9206e3ade260b9634f519919b
25680 F20110115_AABIYK mcnally_p_Page_029thm.jpg
7eb236c49267431ae3814d5cfeeed433
159a2b6b510bf405fb7999acdc06009ea742055f
18474 F20110115_AABIXW mcnally_p_Page_019thm.jpg
b1a55123de25675d22bcb13ad5e0e820
7cc0c872b60d9ef8111652a7b8de2a33149dd44a
77424 F20110115_AABIBD mcnally_p_Page_095.QC.jpg
2c6f5dd6382b59c59fb2eb94ba32c0bc
4bddef901e1fc88618885f8dfef88a6557fea3f2
32810 F20110115_AABIAO mcnally_p_Page_007thm.jpg
967cbdcf7044fbbaab2032389f3e05bf
17b725dd5d352929583edba163b54cf233fc21bc
26294 F20110115_AABIYL mcnally_p_Page_030thm.jpg
72e06e9183f67fd6ee241f6654bcf9c6
f0b663b34ea787c5b6a4e4a46159d0b06bf31aab
59702 F20110115_AABIXX mcnally_p_Page_019.QC.jpg
554e146743d77c3582a550d1c962b6e7
9efc8d461ee7ad371b9e7bfe0a6ada378e8f5227
F20110115_AABIAP mcnally_p_Page_080.txt
a78b0fa226f9f4aa416a29b10db2bdd8
cb88fb9fa80c134cd3588eaf0fae3cd9bfa2bd9e
82847 F20110115_AABIYM mcnally_p_Page_030.QC.jpg
6eb480d14e1ab4de31bf93aaf6ee1515
70b938ba01a57dc2ac49966af3959046f01c13ff
22614 F20110115_AABIXY mcnally_p_Page_020thm.jpg
c919bd425ebd98fec0532c6a4f58a76c
04f3760781dbaa3edbf04044c17e651ec7921c81
75785 F20110115_AABIBE mcnally_p_Page_016.QC.jpg
755d719475b445434ea6770915824217
8c133c52e0b8a5b4c25a4889c8e71c1b9922729e
80928 F20110115_AABIAQ mcnally_p_Page_059.QC.jpg
e6db0c090738051f4e737ceae69f25b2
7dad3fbef92d1725fe0d81ef3ba43ef02f0f426d
20535 F20110115_AABIZA mcnally_p_Page_044thm.jpg
abe492044fc8f5c727b32ff2d201e238
c914cdce1202c733808b622b8321197eeed8433d
74004 F20110115_AABIYN mcnally_p_Page_031.QC.jpg
cebef49845fbc5123fd9dc0925779368
b7a6076017863dad173030982b662b280cdbb5c4
69219 F20110115_AABIXZ mcnally_p_Page_020.QC.jpg
90cf50e2d3445567883c4a0eedb2a5aa
87a835ddc8e02441dfccfafd4e6bdb797523b9fc
98651 F20110115_AABIBF mcnally_p_Page_045.jp2
53bdec598f1b407f50756489d63b0ec3
278b211c4a906447e86fd832ac64263b98343e37
114601 F20110115_AABIAR mcnally_p_Page_030.jp2
5678af3193256d57da91f843d701ffe4
c1f7c2e2fe02b1957181f7b1bdc71d4ad542c7c8
23594 F20110115_AABIZB mcnally_p_Page_045thm.jpg
3a9a4c90b9e32aaccbf1a11270c48434
bcd3439529ea078a9944f68d3e73967f0453c553
20694 F20110115_AABIYO mcnally_p_Page_032thm.jpg
db2498f8a040695dfe8757bbfbc5975d
2ade55da1afeacb3e9ec57fa5fa200cab456a091
24487 F20110115_AABIBG mcnally_p_Page_025thm.jpg
c97880dd87d80adb6de931d7a67d609a
859e287e602378a30d4cdbc0cdc728845351a94d
49615 F20110115_AABIAS mcnally_p_Page_016.pro
9e72dafa7ab4b85df2113a9b40b8fe18
a3c189ca0b81d2f03fb06f9416f1e5904830bc4c
75987 F20110115_AABIZC mcnally_p_Page_046.QC.jpg
525822c6664374c4f91dfed64bdc350c
21037f1045d6daeddb35ea387f19e3024c625af0
65236 F20110115_AABIYP mcnally_p_Page_032.QC.jpg
933f3a6335ec4c75333f0f263a224afb
dd896c704a795adba864cf77efc868a694f01040
F20110115_AABIBH mcnally_p_Page_041.pro
852d900d055c67c5d6f9039250db55e3
7a966998499bda45208bfcf027794b137e7e0294
1794 F20110115_AABIAT mcnally_p_Page_101.txt
ea92298168c32486780ad679d71cc744
59dc1826c00ee7b8a55692224091b4a961e1b1e8
75659 F20110115_AABIZD mcnally_p_Page_047.QC.jpg
3d6ebce3e42c3ee178ffaea83466caa3
65968042027eae1b351688f2b1d5d49ad178e460
46824 F20110115_AABIYQ mcnally_p_Page_033thm.jpg
76ccec3a34391dc305614812aa6ec724
7232d472bc3bd50e9e83b59218379490179f23de
1753 F20110115_AABIBI mcnally_p_Page_049.txt
584ee04b8741b331df20f8061c23ed93
c0a52a2f54b38c09f9dfd8874b3fc0649e93bc65
210320 F20110115_AABIAU mcnally_p_Page_027.jpg
a123c797d996972aa077a7a349015ffc
21abeac20bf2a3660330c70a9da7f2a3d638a61d
12910 F20110115_AABIZE mcnally_p_Page_048thm.jpg
d272ba673471b0f73df47f0483716ea9
5946d32b3fa8d59b18cc4c75ff9f498bb961c951
94173 F20110115_AABIYR mcnally_p_Page_033.QC.jpg
abc09bdce3bd0e59e438e9a55029887a
1b1463b9d61089172a48017bbc44fbc2ef514be7
201377 F20110115_AABIBJ mcnally_p_Page_037.jpg
1d0a00aa72c7e30881c5a2b46b8af8f8
60e9e94e6bae766811939d8299f7c42b512e4d51
73620 F20110115_AABIAV mcnally_p_Page_014.QC.jpg
e736a31df7e3c70a73ed88f2253716bb
9004b13ab51597726bf8dfe24e224de054653b61
51702 F20110115_AABIZF mcnally_p_Page_049.QC.jpg
93f0cf1cd77f12a89a6311da6655410a
549bc9dc9f0bb8accbbebded57ce66a60cfae10f
21144 F20110115_AABIYS mcnally_p_Page_034thm.jpg
8013cac265112b99fa46dc466581e809
2c918befbe0e169dd801791ac30940f802b59301
119250 F20110115_AABIBK UFE0008386_00001.mets
49ee3459e6086e6e09858bab75cbec19
b02077132d13a860c06981e9b3ed222e4c1467a0
33361 F20110115_AABIAW mcnally_p_Page_094.pro
65e6138d0fdd3343d15d0af88e8ac281
bf3c972859d1e098f707044fa7679a07ac97ea52
20570 F20110115_AABIZG mcnally_p_Page_051thm.jpg
5790caacd77d99b8093adadef6f79cc9
6c49d9f2fb2748f050df17c3abf7c1c9ca50dcb0
67060 F20110115_AABIYT mcnally_p_Page_034.QC.jpg
5106114c84faba37c432e1617da1e316
e22ab6eacc74a9806fef18ab7cb04a087d172370
204278 F20110115_AABICA mcnally_p_Page_014.jpg
1af296e6a70a9cf1b59148873244084f
52149dbe16c935b3a5fea0920f56d1b145fda531
202329 F20110115_AABIAX mcnally_p_Page_047.jpg
b54818e1c62ed76122199b3de83ae833
85539646802e20f2f90c3cae8c990dfee50c435f
20329 F20110115_AABIZH mcnally_p_Page_052thm.jpg
5af0bab8f89e0abe6c82e4a503b68cf8
1edf1e034d43a8ed3eca0c176643383a1d83051d
18977 F20110115_AABIYU mcnally_p_Page_035thm.jpg
86a5b38b24657949b9c34f6bb5c811eb
769ed814b6560258b5285c76b87ff5308099f076
206799 F20110115_AABICB mcnally_p_Page_015.jpg
ce54ec9850f3b48034c3657d4e29b54c
4318888fb233a1435e32c206521e7e1e03426de9
262608 F20110115_AABIAY mcnally_p_Page_099.jpg
2ae49c47213e78287f439285c05a94c2
6853d8759ab96118f7d4a876e60905886861eab2
20833 F20110115_AABIZI mcnally_p_Page_053thm.jpg
26767976d5dc7d75304efc8b91936ab9
7a89fa99f4cbd946de37160f087c12006485f16f
59831 F20110115_AABIYV mcnally_p_Page_035.QC.jpg
d86dad05829e2063b3e6aa2e371f9d22
03c18c851eff42e6bd7ad510546760ea343d5fb8
204530 F20110115_AABICC mcnally_p_Page_016.jpg
cf40b58814dc0e61539132609ff847be
03037d007a669ae7e91462a008381978291571aa
62852 F20110115_AABIBN mcnally_p_Page_001.jpg
6ce69cbaa20616d457fd4e724ca45108
689269b42abddfc12efbb9722c852f3c81cdde9c
84842 F20110115_AABIAZ mcnally_p_Page_083.QC.jpg
255f50c553177feff9a89545b0fbe74f
d12ff22b8db140eb32e44b12526022ee8a3882aa
64236 F20110115_AABIZJ mcnally_p_Page_053.QC.jpg
1b194cbebfe6980fbf7103a2506e14bb
a4887b22f0aea21a42c9f3473b6b92ed9cd5e26d
69064 F20110115_AABIYW mcnally_p_Page_036.QC.jpg
87307756c356136414272c3813f8dade
c66e9ef1afaeeffb1aae63042d0979108500f721
199976 F20110115_AABICD mcnally_p_Page_017.jpg
55de2bed9e10a69039e1d69aaff6aa50
418edfa32a51f8ea47c4bd1871336bce3f7ee860
15041 F20110115_AABIBO mcnally_p_Page_002.jpg
e312732197cd11eb7bb429e4d4840a67
a08c644df8e9afac9e24af3f79d37b7327f595c8
18785 F20110115_AABIZK mcnally_p_Page_054thm.jpg
8dc48149103258908b1c5ac20a4b5187
f3100583cccb4851babdd4d6c33522977fafe5d5
64708 F20110115_AABIYX mcnally_p_Page_039.QC.jpg
980502b53184540a1610c7daf0a03afa
8a29cc90489a4f3ca54ff1d438a2bc0bee1c3674
178923 F20110115_AABICE mcnally_p_Page_018.jpg
5246d462f1da8725a392b4a13050b23e
02ad3b25d99c8a18c49b6e7861bfabed639b26cc
11766 F20110115_AABIBP mcnally_p_Page_003.jpg
268d1057299277772907eeac63e723cb
7d96f9d6c30ac7c376a0e705b6bb90f4aeef5e27
60006 F20110115_AABIZL mcnally_p_Page_054.QC.jpg
76d59ae3bd731c95a71462273493da0a
1b0aae34681526165284929764c7dbfaa83f4858
7563 F20110115_AABIYY mcnally_p_Page_042thm.jpg
1150aa7d757deeb7143537bcf484927d
106b54e898e6ef46da79cdbc501529603957ae2b
170242 F20110115_AABIBQ mcnally_p_Page_004.jpg
53716a17581e299a9f82b551e7021a06
bfc667b52f0050543c66a06127fd8a3313807e54
20100 F20110115_AABIZM mcnally_p_Page_055thm.jpg
4fc287320fb48e7cbfd4d4bada551a0a
00793af3762df4a36944b8a03735236a08b95f98
65042 F20110115_AABIYZ mcnally_p_Page_043.QC.jpg
3f7ed6d1e1129eea3296dadb67dd8c28
cdc1a4a83d13cccc1c04a2dbdaf9a24ddf8fad06
182593 F20110115_AABICF mcnally_p_Page_019.jpg
864ed9567c1e6d873599f9e2d7444e6e
bb3bb9cdc5b3250f98c717c6de77ad1e7adb29de
267017 F20110115_AABIBR mcnally_p_Page_005.jpg
f3d50deeefe836384c21e14c2be912e1
de9c6bd1dfe8503f976a12074f1a465d320fca29
24253 F20110115_AABIZN mcnally_p_Page_056thm.jpg
a4030716d286c92fc2f4c539376a5be6
5addddc36c844e9773428eb6ab7b51e377ec4518
192289 F20110115_AABICG mcnally_p_Page_020.jpg
c7f568b6fac8c3f1603fb2a949d00fef
4a0628076f8fa806d283d8bd95511194350cace4
311668 F20110115_AABIBS mcnally_p_Page_006.jpg
7e428c4c394209f4c64d5ed96649209c
0c588cc5d9cbabb4ac8733a16bda31e5e6353a47
77730 F20110115_AABIZO mcnally_p_Page_056.QC.jpg
5ad37e52d0ba1ea22382ea9a0c27c208
1d1d426f5ba98ba63e4fe98a1efd8c9414cc8a6a
190251 F20110115_AABICH mcnally_p_Page_021.jpg
61623c969884d8369fe9bddcc5631fd4
7b75e50a38edaf1d6144e831cb0a8bb8f4c2b8df
82035 F20110115_AABIBT mcnally_p_Page_007.jpg
7e0f5ea430291129b3e52be35450b928
4f1430682d04bc93ad12e467a9efc7866944c754
79742 F20110115_AABIZP mcnally_p_Page_057.QC.jpg
c8bb2f742ff27628587a1deb220f0622
b015dd9283b92e5656380ad6cdd72bb4dab20f33
204393 F20110115_AABICI mcnally_p_Page_022.jpg
cad55b35e156ef3c33f07ddc4d9eff94
85bb44149846a7e915acb0cdb99f1ad729301c1c
164143 F20110115_AABIBU mcnally_p_Page_008.jpg
f1b8cc1dd3bbe199c5a258132536a6aa
d4b5a9494a4c690a92f6de81c6b7603439167c1a
23798 F20110115_AABIZQ mcnally_p_Page_058thm.jpg
9e8f773e08befbf9925fedb887b33d8e
2f27101fd24556c42d48fb1fa03082999eb7435e
199416 F20110115_AABICJ mcnally_p_Page_023.jpg
06b51e0ff6d3871fd809c568875a68fb
9c30468db76d11ab895a0894875860f41744eace
166256 F20110115_AABIBV mcnally_p_Page_009.jpg
72c260d656a71c15d963436e040366a7
a2d804ed0dacb41736f26740018cd4c9d0e16db2
24884 F20110115_AABIZR mcnally_p_Page_059thm.jpg
83a2cedc589af9326de417df5082b467
4db7503d75d100d741c2799e7197e6fb9608c244
203545 F20110115_AABICK mcnally_p_Page_024.jpg
9b3838fd531072757438c6af46ebb533
24c411a7f1b7a5c563158938a739a5fdcf0dee51
193811 F20110115_AABIBW mcnally_p_Page_010.jpg
9a6ccc2a5c7fd6f4e67ea6045bbefcb4
5e8e18c57ed996b814a1abf2268181afc2e66f4b
80092 F20110115_AABIZS mcnally_p_Page_060.QC.jpg
b5d52dfd42dc978ac8206a5bff763122
6aa53c2cc2b395546ff45007ced8892b607aefa7
207136 F20110115_AABICL mcnally_p_Page_025.jpg
884c4d28155ade1c54d728d25c4e9715
04b774722de0013740edf5ce1b1385eafdc294f8
177193 F20110115_AABIBX mcnally_p_Page_011.jpg
4fa393e8a0e47acaa6ea22b2b75ca65b
2e525fa1c7743971edc27aeab1e7a409c414f8f7
15458 F20110115_AABIZT mcnally_p_Page_061thm.jpg
eade0f91b32bdac8f733b5b374fe8eae
d20c51ae62783cfe0b9ebf7c7861438fe50ee2b0
51068 F20110115_AABIDA mcnally_p_Page_042.jpg
195c6226e5f56732e5849ab21bbe4a76
a92440b78fe8d0260424a5e055b11050648b3756
197895 F20110115_AABICM mcnally_p_Page_026.jpg
95beae86df7d97e09950993c134e0371
85b7eebee74bf3677ae24acbbc0edcfe8db01a60
205969 F20110115_AABIBY mcnally_p_Page_012.jpg
914f52734ef9e95989c74e9c3d7270fa
95dc8416c0347071e48d442be9208e5919a96fa0
2796 F20110115_AABIZU mcnally_p_Page_062thm.jpg
ae5234382f98aff3f4c4ff6466c2a20d
2c65ded6afdbefad4c0692f3c62c486c8f862a83
176176 F20110115_AABIDB mcnally_p_Page_043.jpg
81c1e54d5feed3a31547e29e50618b6d
67e872eca9433a89fa872fb43b1212bad21679ef
219537 F20110115_AABICN mcnally_p_Page_028.jpg
0d94d0a008569c5bcb62a3d497f750ae
f96601c5b59a26932e248079a0dd273a7dacdb65
183070 F20110115_AABIBZ mcnally_p_Page_013.jpg
51efa01a2f0d4d9766d040b34488e6b7
eb57c0c05b780fc2b8208b6e7f1d071f7edd9992
68593 F20110115_AABIZV mcnally_p_Page_063.QC.jpg
1947300113319b08fe0c874c8ac6e259
67c9c1f0392e9344555ed39a8a80140bf20b9bb3
176152 F20110115_AABIDC mcnally_p_Page_044.jpg
0acc2f82167604b222dd654bb6dc79fb
ff3ec6ea929e086f0fc39e3eee0e4892a688aed9
214421 F20110115_AABICO mcnally_p_Page_029.jpg
23d80784ca86c505e404125019428726
1ca9a3efafdca9486b19a334e2ad83c6a69492c2
77307 F20110115_AABIZW mcnally_p_Page_065.QC.jpg
e591250639cc7f0d631c3b3b99cbc1d5
cc5ff8cee766d351a10cf4a7d5ac390ff9a6e796
193126 F20110115_AABIDD mcnally_p_Page_045.jpg
493a78ad2ba40d426f44e0ca2f2ccea2
bb568ba5d67287169be46ce4cad57f8655a7d858
221573 F20110115_AABICP mcnally_p_Page_030.jpg
f1ebed331f6e0f331790549fcdccc321
a15a49eb5e3aaec8b78320af7e3b02d64eb9064f
87735 F20110115_AABIZX mcnally_p_Page_066.QC.jpg
87f0e4e5551ac8606abd245a0f6a242a
5d97f53e2ef1daa705e06f128e059d191011da44
198578 F20110115_AABIDE mcnally_p_Page_046.jpg
8ae40ed4abcc3af981f9ec7a6e024a83
6fbb1e54322ec7be2515d1bd2d87fad3983d67f4
199907 F20110115_AABICQ mcnally_p_Page_031.jpg
2804b25f2996ee86086a91bb7d2ad14b
5813fb9b76c97b342503f5d02b29636d07907e44
83941 F20110115_AABIZY mcnally_p_Page_067.QC.jpg
ed865282007c1f0ac92b6337fb7195eb
d75f65547bebf25d164298bee95a4d989d70888f
105104 F20110115_AABIDF mcnally_p_Page_048.jpg
02c9ad6d4c2ed37226d159f71711016f
de2ecd95ca3276019d2e378cb31ac1aeffe271d5
174705 F20110115_AABICR mcnally_p_Page_032.jpg
f5d74fec7feb040316fb10c0e2881679
bed3d3e31dbe9766043b25be94a1b14a95aca2d0
6772 F20110115_AABIZZ mcnally_p_Page_072.QC.jpg
48d3462bbd077dabb2df7df03a65f846
a6fa76476b31346f8dc1e64c1f0fbc60570f0d37
224342 F20110115_AABICS mcnally_p_Page_033.jpg
d2a798bb03f794b45208b53005c8abc8
3de5a30999a8720e712db248fb5c858fb955befe
156943 F20110115_AABIDG mcnally_p_Page_049.jpg
fb66c1e173b22b8fbc3735702d304463
b456eac58d57496a0c2e0aae87365514fa2c1c46
171501 F20110115_AABICT mcnally_p_Page_034.jpg
1b84772fe54f7c4cd48ba7820f1b93e9
645a04e18e1dfdea0d240bd0b28d8f4a0ab33f80
108321 F20110115_AABIDH mcnally_p_Page_050.jpg
dc4ca06e6c51ca2bd22f06a9dc2cadfd
b1b34faaed500e07f5e6e336432ea4b457766c25
156127 F20110115_AABICU mcnally_p_Page_035.jpg
36eb383a599f0d1fff44b947c7fe5bb3
77dd613429bb965ec33bdd1fe4cf97d7fe26c257
184778 F20110115_AABIDI mcnally_p_Page_051.jpg
50fa46f5f0bd6a5b5f26ddc6419e68ae
0cf90f6b07a27938cbb4bf6fd95fa1678fab8fd6
188424 F20110115_AABICV mcnally_p_Page_036.jpg
770105b84a9092c1737eb26532cf3c0d
3a437ba23b93304b1b34bc165dc9e110ce593a5a
185444 F20110115_AABIDJ mcnally_p_Page_052.jpg
b694249210da119effee86fe138a1fd4
4e0d79a4550c4824dafe30d8611122d5cae38cc1
193840 F20110115_AABICW mcnally_p_Page_038.jpg
70b61d86c379ffcc0cd7e9cb26aa2364
d95206940b67b0f263517338c08aca73f1dc27e7
184081 F20110115_AABIDK mcnally_p_Page_053.jpg
dad163c3b410e0c5f70574b978ad0e9b
3f0daa52e82d8a0af3652886d3ae43291cb992e3
176698 F20110115_AABICX mcnally_p_Page_039.jpg
75e448e36809475c76abdfc4605011ca
52cef1eb902d17858a87e3fd87418310c313def4
188670 F20110115_AABIEA mcnally_p_Page_070.jpg
30900408ea327628e9a58e4b59732637
a68ddfab3d71176ee1ff3288dbb8fda0052c1a2d
157645 F20110115_AABIDL mcnally_p_Page_054.jpg
e00dfa55fc980b3999a352158ddd7703
17880e8945ea77a6149f525f11e7e182ecdaed3a
197997 F20110115_AABICY mcnally_p_Page_040.jpg
d56fa06aec67fe2ff76dbf06281a8497
ce1158ff3d1779117de7cf5f59ee931a534e087a
171579 F20110115_AABIEB mcnally_p_Page_071.jpg
a08253a45eeeeb10ada6511a6fa85baf
0dba537346cf9941a3e108013a244f276aedd091
203101 F20110115_AABIDM mcnally_p_Page_056.jpg
1aa12fce3e1494c4a4178c4aa4d184a5
3635136d1fb705c0884fbd63442e8caa5ac49fb7
211136 F20110115_AABICZ mcnally_p_Page_041.jpg
8ce2212eb414c880e71902a091158610
2d95b12f33811c5d29cf44e1eadec7c575dbeaa6
16985 F20110115_AABIEC mcnally_p_Page_072.jpg
e28f651724ec86136852c2297f98479b
907d982284f96f665f4c03d607811105f0f8ac0a
215939 F20110115_AABIDN mcnally_p_Page_057.jpg
75089e2ee4d1d96698a89f6fbdb3d742
3caf9718bfedc5638588b7bb90e54d43e7294aac
178776 F20110115_AABIED mcnally_p_Page_073.jpg
566e0d1c3e58ce0c97bf0f8feffe7468
1571d2dca0ceb37fc7cb1c366840ed776712c654
193309 F20110115_AABIDO mcnally_p_Page_058.jpg
4d9e2f9defaeda71ae47ea43b146e1a5
71b1d0d2e6f7a374ad4d59e4c3d9611aeb4dca83
225512 F20110115_AABIEE mcnally_p_Page_074.jpg
d9be7a331e1b7ff2c72a399e6117cf69
ee226167d6c733f29ab4ad299bce4dd5723361f3
211787 F20110115_AABIDP mcnally_p_Page_059.jpg
0acb9ca87fc4ba355a65a117cc6fa899
d8c6970bcad73b3d2a8f9067e01b9c795225335f
214930 F20110115_AABIEF mcnally_p_Page_075.jpg
184b1facd36c55632b03d12477475bf2
4740daf2e7c251ec7b030e7d072e6dfa346b8a49
206624 F20110115_AABIDQ mcnally_p_Page_060.jpg
85fd240b6266d857ff8b9ab97fb145b2
a574e2e03566598403bb694bfd1e4a12e6d600fb
219357 F20110115_AABIEG mcnally_p_Page_076.jpg
e040fdc8ca6de00421eac83c74635a03
25dd2d6de881d0435ea077588e3bcd9db2d37775
119376 F20110115_AABIDR mcnally_p_Page_061.jpg
081d50140f1f4dfcd4b3c00341407fe4
80175240bfad51b38b80040553eb77d9c6ccdaef
14653 F20110115_AABIDS mcnally_p_Page_062.jpg
b80999ba65cef3fa4b07149218025132
29c02379048eb812b7b8d7103356be4d1a961885
218108 F20110115_AABIEH mcnally_p_Page_078.jpg
2cb01e2ed32a0822ea0acd43a6e7a347
1994caa03f22d774c5f80490853f67b40f3e9391
172665 F20110115_AABIDT mcnally_p_Page_063.jpg
a33881728d5aca37d8774bc4e60283bc
2257e416c129a249a98005cc343815c036f56445
169632 F20110115_AABIEI mcnally_p_Page_079.jpg
ca202055a864befaf71cd0d6b3e8937b
e031d7d1477b9b27eecec115a03d397ee534c220
16956 F20110115_AABIDU mcnally_p_Page_064.jpg
e870e71a9fc9c8e850ca9a87a031a08b
e4884592bc6595beae1ba8b9bd862d42d6543221
16989 F20110115_AABIEJ mcnally_p_Page_080.jpg
b584f379e30fad4e8b482996a9ce6513
d4e0984450a85573c54ecd9ac4313a3518526978
193563 F20110115_AABIDV mcnally_p_Page_065.jpg
86a0188559b0c2dfb88c5019cdbb6b44
837ce85a004b1b4faf56cec13ae4fc089e297708
189788 F20110115_AABIEK mcnally_p_Page_081.jpg
ef4a2067fa3a710989ef635cecf61d68
b5c7205f1d8dd0224fdb6ec9ca58e0c2e7920a34
236172 F20110115_AABIDW mcnally_p_Page_066.jpg
83dd2a1a0bc7f62ba2298653b19fd003
0c35988e4f232e2fe16d50b3c720c2fc98e04d7d
267462 F20110115_AABIFA mcnally_p_Page_098.jpg
377056979a734a6ed883b4fcbb3183dd
a86d575f0dfe138713f77c94b42eae58a31ff27b
230826 F20110115_AABIEL mcnally_p_Page_082.jpg
b962599ddc3c0c0729c112a38f928d95
9f70521b28bbae6828b07cd881bfa3f327c3d1b9
217202 F20110115_AABIDX mcnally_p_Page_067.jpg
01a43e098b8d3168eea77248c79be705
5b2c8b74794d79ad9f53ab14e16c16b25265a3cb
277913 F20110115_AABIFB mcnally_p_Page_100.jpg
f7e8a5835ed88f83aa0d7748115ab6a5
bc893ede1f1e6a571b0c1f61223d5a71f81beeb9
220246 F20110115_AABIEM mcnally_p_Page_083.jpg
c7b61106b5338628bfb41c92c0fd989f
2bff8c6997361979696b1a2c73ffd8d931a1fb9e
239967 F20110115_AABIDY mcnally_p_Page_068.jpg
06aa8c4318f274f5ab25732d9f8b9e23
8249e97bd2c786f6e60b752675fd2737a8a6fa46
175343 F20110115_AABIFC mcnally_p_Page_101.jpg
746d43f7266c4e08d8cd8f9f8773e9ed
1ba1c7453bdd53c7726cedfef8166682d5c41928
238621 F20110115_AABIEN mcnally_p_Page_084.jpg
24b848a8657ba8be6db90ea9a89246e0
11b92b66e8fcba729cd570e5e36565a5d0c3f062
213682 F20110115_AABIDZ mcnally_p_Page_069.jpg
1e9eb2e74f9697af4eb846cd5f648cdb
5551f0adad8ea551b368c50a472e3c36724e0b05
105852 F20110115_AABIFD mcnally_p_Page_102.jpg
4db0bddc967cb4a07c6a596679b8277e
efd7e03375b144c7f2bf3d40a4a22a9a4b30c38a
209512 F20110115_AABIEO mcnally_p_Page_085.jpg
a2f9193096ad0189472e0478070da60a
b08ea518f4ee70082e02eed98c5aaab96075859a
25730 F20110115_AABIFE mcnally_p_Page_001.jp2
9fbf534e00c94843b00ad93dddffab99
3438052ce676923cc9391f7da0f17537cc7b7b24
225871 F20110115_AABIEP mcnally_p_Page_086.jpg
63b09946e955d12922012c164a2732ae
f17fd508d47a29b12fa441b70538425d5ad576eb
4069 F20110115_AABIFF mcnally_p_Page_003.jp2
55f3de0c1bc388cd83ad33d006179255
8559f8b95646d59192a33e9929da1abb8257c776
166589 F20110115_AABIEQ mcnally_p_Page_087.jpg
66e6dbdf58be89ca1265ff907aadfdb2
6690414bea52c1884b0fa29d6ecfe0f9818f4e07
86539 F20110115_AABIFG mcnally_p_Page_004.jp2
cf9c0d2a229c79c155e9afc62ff5413f
cfb5429b38eb50fff1675a31f822bd53f681e314
149816 F20110115_AABIER mcnally_p_Page_088.jpg
a545a37ba3bf0b6371ad29cd9dfe3d88
e50d2f46becb2c589736e9df46601ff3a848f8f0
1051983 F20110115_AABIFH mcnally_p_Page_005.jp2
fe2a3f6a3e662aae336a451304d8b9a4
6f629ff481694d08d50190e66b5324097709a23f
146141 F20110115_AABIES mcnally_p_Page_089.jpg
9bec7cc6ed8d4d238543c7d1e8e07891
7c043d3c3523d564b0a880deb47b855d315a3f30
144827 F20110115_AABIET mcnally_p_Page_090.jpg
51c7c17c131c8155cb6fbd8ca95e02a4
f0048bc9b7c6c9946b7d76613369cfbefb49e340
129506 F20110115_AABIEU mcnally_p_Page_091.jpg
5fbb8bc02f6e78f86f48acd35f22ef73
7c1c92dee37e103723d2a66894a122bcc4b05b8c
F20110115_AABIFI mcnally_p_Page_006.jp2
48d1c6e62acc5c2fae9a811d9e079856
d3ef2a2fe1aace3d586027441126602e14b7bcf3
141765 F20110115_AABIEV mcnally_p_Page_092.jpg
f2a02a9613e588e23bc0572a7f130a8f
1c2ea226ef7180051964bee990d428928707b1d1
411909 F20110115_AABIFJ mcnally_p_Page_007.jp2
c25703568bb97b29d946a8eb78202145
6c73cd70ba501210caf71289a65278c123e465cd
133467 F20110115_AABIEW mcnally_p_Page_093.jpg
4d2d5b8a2db4a514180e26558542eeac
e971d4a73aa9da12398ba96ed16cfe59deb7cb39
1051973 F20110115_AABIFK mcnally_p_Page_008.jp2
aa333c4e40208402df41f9bebbe15be2
9c35355a37d609440bd729060ea800c63a884d71
176932 F20110115_AABIEX mcnally_p_Page_095.jpg
34d960fc0fa4486eef5e7010926d9520
71a1dcd8a25b3d2432efdc4effa6530087c3b060
104209 F20110115_AABIGA mcnally_p_Page_024.jp2
0fd31bc567693235a4b344aa34f8ba28
f762fd0b5954b61e5b18d11be90a853254d22ba9
82221 F20110115_AABIFL mcnally_p_Page_009.jp2
01d16b5ff6d0462d5054b20726bf9763
031c3cc48bbe287faebce71f7afd077e46e561b5
177167 F20110115_AABIEY mcnally_p_Page_096.jpg
dd4b901800f721517f6c5e1df51bf7ef
d1cef84e5bc62f1ad45abc79c9b7111a0a08b09a
107995 F20110115_AABIGB mcnally_p_Page_025.jp2
90a49ff6bc56c2ab19beb636d4605ba7
0c8c6942b07c05887cba239f379706048ca3e44e
99414 F20110115_AABIFM mcnally_p_Page_010.jp2
f37ee7acc864705180da5370ec225574
d9619ebb64a0e050ed200c155a2aaafd516cb221
220365 F20110115_AABIEZ mcnally_p_Page_097.jpg
f12b3b92fbc25ffa2016c137ac164bd7
17da0c66d1ceb1c74c8e8ae8d4c0ebcb3ec97177
1108 F20110115_AABHZT mcnally_p_Page_091.txt
9aad58f44cfa1a1ff2c92b3b530c039a
f525676d0b89ce718ba63ca53e596bf9ade3f38b
104426 F20110115_AABIGC mcnally_p_Page_026.jp2
836d3fde0b2d5271aa435f62e08174f6
a26dc4501614c1cd23be23dd924973f7aa489d84
92968 F20110115_AABIFN mcnally_p_Page_011.jp2
50998098b22e161f693e07f63b05bde5
e213ec21e9fa54542001b1e315786d451549324d
73305 F20110115_AABHZU mcnally_p_Page_040.QC.jpg
49dbed36fa58eb6e9fd1e23bc496aeb9
d4887ead428a16723603a298d5e7bb05e299d320
110782 F20110115_AABIGD mcnally_p_Page_027.jp2
775423dede6f6bdbd0f3439dda7c4a7c
862223d1a26616da607c53cf33c84b6661cf491e
107767 F20110115_AABIFO mcnally_p_Page_012.jp2
c61db4533fcb2d3cbf9b0dc4cf4bdc69
6881e84aef5b9577ed58086ee50bc6002f89dff9
48416 F20110115_AABHZV mcnally_p_Page_026.pro
4f569d875b7f3a5d3909dcdbccf3cb27
9e5969934f5cc8e9ebca6d5b279a41edd3389833
113878 F20110115_AABIGE mcnally_p_Page_028.jp2
079b4650c7341e24a249bc10e59df7d6
43956f56f1d8878d73bf6b618b28753acb24462a
95832 F20110115_AABIFP mcnally_p_Page_013.jp2
a4edbd396eee81bf858467fb47fe96aa
471c853880aaebb3545259997087ad19a16fb8d6
194761 F20110115_AABHZW mcnally_p_Page_077.jpg
45672cbd8c303ab2acba0f1fc738841b
4d2e532945ecbbef57e4a561405aa53832ca5d19
112822 F20110115_AABIGF mcnally_p_Page_029.jp2
809b827a43b3c39f436a46dbc8825ee6
af2485edde4caad5ce884aa25d80080c85b6544b
106544 F20110115_AABIFQ mcnally_p_Page_014.jp2
85eeb919bbbad627ded04da3bed0267f
f387502a55504058e18391190f0a11d86ef6b82a
1775 F20110115_AABHZX mcnally_p_Page_018.txt
e219347b08a4bd7ecfc5d596fc62792d
8b9098e2ed718577c94157b3cd803f729b54c643
104882 F20110115_AABIGG mcnally_p_Page_031.jp2
64ac992ffdd74dd39532312f655d7caa
ab47897f17699d53e737a4d6e10a781ceb5e55c9
106819 F20110115_AABIFR mcnally_p_Page_015.jp2
f476a6715fcf46c432caa9e67a292edb
0fd4261bbb241fb0781d79d5388249d48497f758
93136 F20110115_AABHZY mcnally_p_Page_043.jp2
969ccb655f55d11751f1bb3e4ddf2a88
a5fdaa318ee4340858d16c71e5a96a1fe05cb5c7
90858 F20110115_AABIGH mcnally_p_Page_032.jp2
503b84448869f854ac55d4fce65480da
15607d91ba5471a74edc2da4e47e765fef87ce42
105395 F20110115_AABIFS mcnally_p_Page_016.jp2
2bfa6ff5efb583e5b4842bdc34e96e3c
122e9469188ef03755ad00fe2d227d5d1380ddf4
F20110115_AABHZZ mcnally_p_Page_034.tif
722b8352519b6dac2f46530adb138f6f
f982955306af2b9816eeb6d85b3595a8d1bea385
1051976 F20110115_AABIGI mcnally_p_Page_033.jp2
7c63e703e322658235170148adb95b90
a9d3abb0953c09a2e50e61c53bdc9da6cdc754f6
103366 F20110115_AABIFT mcnally_p_Page_017.jp2
ba2345eebefb3df08a9ddd0e0066528d
4a71e96897b084a93668bae58263a80e41131b27
92701 F20110115_AABIFU mcnally_p_Page_018.jp2
e37480d864c70be78a331422b6428c98
199d2102d95c3e07b6e5e7d2c4e9893d1d43a7e9
90805 F20110115_AABIGJ mcnally_p_Page_034.jp2
0d2726ef3a4651e6d49ada607e0cccaf
ceac2ea61bfe05848eca468e79e7979474b949da
91141 F20110115_AABIFV mcnally_p_Page_019.jp2
251475d2617199eedde80f4909157d6d
f806217df45c8e403ee1351562f95f59dba1fd12
82624 F20110115_AABIGK mcnally_p_Page_035.jp2
912dc4c8f8eb6cf9039a68dd57f94841
dec290f603faf8c25a7b7270fd989775c6096b1f
98000 F20110115_AABIFW mcnally_p_Page_020.jp2
1e542788fce142c858b5eeffda4d54d0
bf46371675d598786b023c3a9e6ea14eafde6481
82732 F20110115_AABIHA mcnally_p_Page_054.jp2
870cbf8b5a37f9c927073572b3957b63
8939555b1541f3375406305642d3fc3bf5863996
97595 F20110115_AABIGL mcnally_p_Page_036.jp2
9f0359f063d0af9ea2e1084940c5f64f
c4c28c153e092bbf5aa3dd85636b8f91e0a9a439
98935 F20110115_AABIFX mcnally_p_Page_021.jp2
395c0566cd87a1c2d7653cbea6609b94
5f0bfe2a678ba7981475687893f6bceb4c1ee905
90369 F20110115_AABIHB mcnally_p_Page_055.jp2
64aed3ea47b5de0689d119f19c8761f2
97be350323d73a763b1781398e46b6797db6bba0
105314 F20110115_AABIGM mcnally_p_Page_037.jp2
f24417df7dd833b923f08fa5dd51112c
040945f6e033a5be9f6c74b025e70fc996ef0788
106862 F20110115_AABIFY mcnally_p_Page_022.jp2
19bf717f339414b22dc206087fe50686
4d29a78148a9c50a4c14804a869aa83f01ebf1d0
107063 F20110115_AABIHC mcnally_p_Page_056.jp2
f334cd198dc01197ebcfc1f8a9ee274e
df3faf75660919eecc8551e8565a71168037b699
99894 F20110115_AABIGN mcnally_p_Page_038.jp2
bc87ffb92cceac5fd20d7f3904b65dee
b69b734a7c09925f0f34b3ba46aba692d5f0482a
106050 F20110115_AABIFZ mcnally_p_Page_023.jp2
0bf9a9f13064d055df43eb1dd968933c
cb28aad985648857b76e76868d9cdc53c53a4090
110217 F20110115_AABIHD mcnally_p_Page_057.jp2
bf8055af26d702b44077e9ac91c6a2ba
15b5691c356608651465add06d18449dc6cf6059
93562 F20110115_AABIGO mcnally_p_Page_039.jp2
69c5ab8864e86a81111677d8fa9915ec
8888a98a11d6db2a83e64c78b7eda66f45ebe65d
101599 F20110115_AABIHE mcnally_p_Page_058.jp2
830255897e039d6cf335c90b80e50d0c
6e16a16ff6cd97eb96cf820a3ac22482e90d9da1
102943 F20110115_AABIGP mcnally_p_Page_040.jp2
84bd8fc4fc0d110fa3823b440221481f
b9af89e7ad21d5af554a73eaadab2ee7b2eea835
110511 F20110115_AABIHF mcnally_p_Page_059.jp2
f8a698008c5d2232fc5ec80ee0313cb2
1171aa22b412ec12205d99b52a0ac6723931869c
112340 F20110115_AABIGQ mcnally_p_Page_041.jp2
67a669016a47a577c3dd07f70470a3b7
c5bd85fc2b5757bcbba51093d8e390542d7d72b0
106350 F20110115_AABIHG mcnally_p_Page_060.jp2
2140d7eae7cd874da3d6795dd34597e4
b412539551b6c95ef295106fb92236e2898d6ad1
26389 F20110115_AABIGR mcnally_p_Page_042.jp2
c0918d79534c737f5630d1376b96e033
71ddcdf47562bdedc29bf7e6911299fbd7617b21
62646 F20110115_AABIHH mcnally_p_Page_061.jp2
b0ce1a2bd61397cf12bed4eba5fd5ddb
197939b7c937743d2c001d7259dd7aaedd810e0a
102800 F20110115_AABIGS mcnally_p_Page_046.jp2
00e3501cfa0d6feac43547cfcf9b56cd
3309610e6ac4d0db2e7a4a0005c1a7acb3c59f6a
5451 F20110115_AABIHI mcnally_p_Page_062.jp2
b7514c4dfb428e9948ec8188744e019b
a801ddc52b858d9577c68fa5afd913eb8f2f52a3
105768 F20110115_AABIGT mcnally_p_Page_047.jp2
36d8ab620e49985c1ef617b4f8958be8
eb44ceab980db08325fcb58ca2564c1d7dcdfe02
789629 F20110115_AABIHJ mcnally_p_Page_063.jp2
f4aef7bf73f445add00c53667c3d77b1
6183191a222b2c9b923c03c079bfa6251b1466bc
53461 F20110115_AABIGU mcnally_p_Page_048.jp2
88c2e4577d857cb30d583c7a72e82dab
1ce0249ee4cd86793097d9b86e946ed157178e65
79095 F20110115_AABIGV mcnally_p_Page_049.jp2
eae61e5bb0bfc67000471b5a46eef9ad
c66523f5cf64f8fc721513b52114820e605de935
6894 F20110115_AABIHK mcnally_p_Page_064.jp2
5c3fff1d9b04a9a5623bd367c6f8cca4
de9605985dc9902186b69b686ccaa743814f8815
53784 F20110115_AABIGW mcnally_p_Page_050.jp2
3f74a5226d677ecf34d32034456cd76e
22ede79d8521902746451f4a0bb354c8f40f13a6
831124 F20110115_AABIHL mcnally_p_Page_065.jp2
44310cc2ab8afc00b5364253a32f6a9d
97d6463ec9493806fe19862e4ad38b737fb161ae
96743 F20110115_AABIGX mcnally_p_Page_051.jp2
b6c11b71cb9762427868c4869370be21
c88be0ca408b5a80ed40eb9a636b24d4a4de8dac
6860 F20110115_AABIIA mcnally_p_Page_080.jp2
cd027eacaadd0217cb38bf0f75d52a19
85f513f4bf5b147f89fbc7e03c9f3e9ace143c0f
1051933 F20110115_AABIHM mcnally_p_Page_066.jp2
40b9b27481b053cbcd5383d34c9efb1c
24bb59a51c427fc4684d1b7482a9b61a1dad0c4d
96627 F20110115_AABIGY mcnally_p_Page_052.jp2
f6c8c5d5a857eae66b4b8a9e0e3c2115
424acad519cf41e81dc77fa791d18d030b413555
1051961 F20110115_AABIIB mcnally_p_Page_082.jp2
fc3dc6dd0170952fd0f41db862799f2f
8f639350af118312151b5123e6e2e1bf5bcd74a5
977495 F20110115_AABIHN mcnally_p_Page_067.jp2
db830f342d507520e7d0cd9343f25fa1
10be4addd296c1151f1253ccc9e2abe675e00bc6
95398 F20110115_AABIGZ mcnally_p_Page_053.jp2
77442955ac5375dd9223733144772dc1
aeafe2c9e81f1d8bd3e23d9d2101dde6d30cf35a
970441 F20110115_AABIIC mcnally_p_Page_083.jp2
a9ca26d13607d9b0152141ab86587f54
60915520a7854eec0ecdb70818d361dae657f0b5
1051980 F20110115_AABIHO mcnally_p_Page_068.jp2
9e36e087a45ed4aa0ce1b3fe4cde2dfb
9e244b12e0e26dc710cfbd474207ff091d95e104
1051965 F20110115_AABIID mcnally_p_Page_084.jp2
c7fc2c5cf96d767733b260bfc50a5a90
5f2a3d609b949bbcb5bbc5aa7e6daacf9a1c6ac0
976807 F20110115_AABIHP mcnally_p_Page_069.jp2
d17c8ea05ae84961860a92480db493f1
6df851b5510d9a254ebab7a989bcf32b2f0221e9
933305 F20110115_AABIIE mcnally_p_Page_085.jp2
c2a74216ca433ededf204a9780e6051f
ee0038c91879ab24ebc765e6d73afb8f0b823861
785246 F20110115_AABIHQ mcnally_p_Page_070.jp2
8887ed57c05930b4c624b25d99721ddb
9d86876c6278805fc8282af09ba42f1eb5500fb9
1006203 F20110115_AABIIF mcnally_p_Page_086.jp2
77144619fca03e2e329cd93867b08369
b8408445738a005f5408a1550e6d8904012cb888
670760 F20110115_AABIHR mcnally_p_Page_071.jp2
3a0312bc356299a983aad3494b3bb577
48cd618263c4e3a23c899822f7d509063155f0b3
654359 F20110115_AABIIG mcnally_p_Page_087.jp2
e168e5ac08cb7fd68fcd34daa1f626bf
97e44aee5af0288c0fc602edd3ec2ab1cd7b405a
6882 F20110115_AABIHS mcnally_p_Page_072.jp2
5d7aa42a5d36e12534f85417b0b611bd
904f89dc8cd3b53e1fd62f89a8ca543c75334109
577939 F20110115_AABIIH mcnally_p_Page_088.jp2
237f8da7bab111a897e721b919a76fd3
060fdd4b43007e9d595301ca76a04e373e0374a8
704841 F20110115_AABIHT mcnally_p_Page_073.jp2
a3aad3d1e5a30c56880cc5be11f65c97
b025f515c4ccf8573fe78e7278ae2297c0809e7c
560229 F20110115_AABIII mcnally_p_Page_089.jp2
da0c3441bf205e47622cbe11ee299c07
056cf4c21213b551d450bdc4de485b031924dfaa
1046872 F20110115_AABIHU mcnally_p_Page_074.jp2
4a5c4d5e4a1fda8e2dcf23595100d2c4
5f9806efd31d9f0b70ca37254d5917bfb787d00f
577519 F20110115_AABIIJ mcnally_p_Page_090.jp2
b19b59976fd844fca658bb8ccb368ac1
bad8c6aa0c4831d093a669fa2f533d782205ff03
928986 F20110115_AABIHV mcnally_p_Page_075.jp2
26913f4e1024e6f30749d160fa725512
14876d198140747007f31af5303627058c283aed
486719 F20110115_AABIIK mcnally_p_Page_091.jp2
45e133907056b1090653e57e2a345ff7
80faffb687bbac4b2754ae519d8d740e9db26ffb
1009012 F20110115_AABIHW mcnally_p_Page_076.jp2
35c9a3b1734352f61081b87c5573a438
8afd6d53ae5f8f14f36d54a24ce67e64e6dbc392
821679 F20110115_AABIHX mcnally_p_Page_077.jp2
c050faee4f9ee04b8eff029c51ebc801
cd95df00b6c4474d36b88ac6f31cd0c107af8f6e
F20110115_AABIJA mcnally_p_Page_005.tif
1568c85128c8cbf9c16a79cfa37cc45b
faddb762ae2a3e4f456a36a82dbaa1bc520d3c03
546190 F20110115_AABIIL mcnally_p_Page_092.jp2
8a308cd3588eafaf026ab52acf287b00
5892b85aa8e02c5226c88825622760f3498568a4
973752 F20110115_AABIHY mcnally_p_Page_078.jp2
98ccfae443ba443012b5363cd9a2f683
7fcf8863ea3d901de018a201fbe74f5370f1e9e3
F20110115_AABIJB mcnally_p_Page_006.tif
6fe4efd4604949c31435f6f2a6074c90
446ffa6ca9bacdb37c6b0be7bd22fc82009ce52c
494722 F20110115_AABIIM mcnally_p_Page_093.jp2
026839b232085cae97dce29340b9a2f8
edfdfedf181ce14a8a01075a775b65f65d1fae80
658317 F20110115_AABIHZ mcnally_p_Page_079.jp2
52d346ec7ebc64ed6840702f73b56e24
57818f997b38a4d8d1b5da74261dd62ccac4797b
F20110115_AABIJC mcnally_p_Page_007.tif
e454005f415d7202c4d1bbad25926a06
d88b655186bff23c192b2ae6882f6b5a2a103bd0
649467 F20110115_AABIIN mcnally_p_Page_094.jp2
8f2b9b62798930f230f8e41a055e2203
ede86f476791d91450638543e3f6f06854e8178c
F20110115_AABIJD mcnally_p_Page_008.tif
5d0e7742d29b502a65edbbe582e083cb
11b358796bc1de7f4b96dae1c24707df89da693f
656522 F20110115_AABIIO mcnally_p_Page_095.jp2
3868ecde5f10d2fb1f33560b0aa853f1
7e335e563e963c8b158a5c3c19eaa2175a66af7e
F20110115_AABIJE mcnally_p_Page_009.tif
328bb0bdb27dbf5be667c2072b457fa2
29f3cfea12840fb28d4c47c53802d7264078ed7d
677003 F20110115_AABIIP mcnally_p_Page_096.jp2
6f043f028d538d13dcd8333f18f4ddab
ef2ff69175632122424a4a364b09cc4a21591745
F20110115_AABIJF mcnally_p_Page_010.tif
633f87cdf19f54377c1f31b36580b93a
d10c245fcf17846422e33a71af1a7404c51c9187
117705 F20110115_AABIIQ mcnally_p_Page_097.jp2
278cc921795d777ed9f23e4afcd4905e
289bcfc13fd8110e08059dd33f3333e0a97d76ce
F20110115_AABIJG mcnally_p_Page_011.tif
2f85736ddeba00688e5f7bb004788c9f
e1f868743b7287f5f30256aa04e40c95e163f59c
131546 F20110115_AABIIR mcnally_p_Page_098.jp2
959c7ec2ff035f6f78165f9b5821130f
55a5bacb273a512c8698878f3a0d9697b8822479
F20110115_AABIJH mcnally_p_Page_012.tif
f4f8ae6af97dc68680d93e6776a481fd
79913b3d83d920100280bc935af6abf6fb965189
129402 F20110115_AABIIS mcnally_p_Page_099.jp2
4548e8fb0534a0bb8d428d01317e943f
6dcc2206928ed48b6330cfb5b6b131c5c365ef3a
F20110115_AABIJI mcnally_p_Page_013.tif
7f948111052e52b39a85960aba198dc1
846f71c62eb914e8be9c4423ee306b205bb112e3
136930 F20110115_AABIIT mcnally_p_Page_100.jp2
0c4ae9d6cf42c4466718b57d5e18201d
ff71ebdd00564f7fd159415525f89758f00f3032
F20110115_AABIJJ mcnally_p_Page_014.tif
a0002204dd7ab0aaab79fa16bb548d70
46272c9bd2781f007b9cb157e37b4c160aa5d0f1
94216 F20110115_AABIIU mcnally_p_Page_101.jp2
d27cf1171da6d2979ae72ba20ae32c67
3e8e3025a6b3f4dad6f32f3d225be9a34f88f607
F20110115_AABIJK mcnally_p_Page_015.tif
99cf71f770a1f5a2846035ed75c49074
b1ae97a22810eb8d05557970a67b6b6405d44a4a
53788 F20110115_AABIIV mcnally_p_Page_102.jp2
f22a270dc7e5a99a9f607ede8f861217
08bc7f28378b4030dda689236049c6148e2032ae
F20110115_AABIJL mcnally_p_Page_016.tif
120be0cd87e6345e1864e611e3fea9c6
75dd5beb7dec4077d9bfa98f4d785d1be97e6191
F20110115_AABIIW mcnally_p_Page_001.tif
7f87dc4d9d9515c317ac33de6921cf00
a280cd5acf6b468972d96470359debc878275e4a
F20110115_AABIKA mcnally_p_Page_031.tif
7d542da412eaff8803996d413d720852
b3de1f343c1c4f19376ba0c8c19381a5709db9b6
F20110115_AABIIX mcnally_p_Page_002.tif
e108122d8a6ad6ba7f2253c27142638d
5d5d0276b406e2425985fa74fbe06e0a9935026a
F20110115_AABIKB mcnally_p_Page_032.tif
2f1cbceb91f51f3596f92b51eb216b82
69dafff9271e09e9a4fed2637405ac94b2d5d03f
F20110115_AABIJM mcnally_p_Page_017.tif
86118903d0cd40617cea5071ab13e1bc
bfec781884674743a83cbf06919de0d5ac08c759
F20110115_AABIIY mcnally_p_Page_003.tif
1129db31e30da33e51af00ff484b5944
d8f9a0ed635a750fd1ae4edc6ae1262d3b2976c6
F20110115_AABIKC mcnally_p_Page_033.tif
cfc34af2109dbea3c6c2bbb4e759ae78
f5552b28eab096c128f3ff5994b8fba55c29522a
F20110115_AABIJN mcnally_p_Page_018.tif
a00f9083144cffdbf6423cc930d649c4
7c354da808b52690fb3a0ffc25ed776ddf464252
F20110115_AABIIZ mcnally_p_Page_004.tif
38e032e3f51d5672d715d130b0f71c94
bfb3369498115a03cd489212fe47ea49be879467
F20110115_AABIKD mcnally_p_Page_035.tif
9218eb501df931e477ab3aa04f19ebff
83186d060ca383e13acd74ff854de60a32b637ca
F20110115_AABIJO mcnally_p_Page_019.tif
720d39e848d4bd77d213559e05fed568
20c5cf78295f1f3812b8fc6e2e53bb0e1fd48edc
F20110115_AABIKE mcnally_p_Page_036.tif
3c4a0e7c63115e3c63d111f0f6d521ea
85793c30118ff8b425fb1a6c9211dcae4316b1ef
F20110115_AABIJP mcnally_p_Page_020.tif
8226a803c47b9912012321f1154760a6
ff60cc7a917aa30192ad5941239a322e6690e49e
F20110115_AABIJQ mcnally_p_Page_021.tif
73f91b62723f0856dd3c4636e0ae650d
5eadc6201515f655e50ecd4fe0a1a214bdf18f92
F20110115_AABIKF mcnally_p_Page_037.tif
8875f335dc200483929d15ded668c4bc
e64a17e448d699c50b0791f2bb0537dcd66110a4
F20110115_AABIJR mcnally_p_Page_022.tif
71dd0c906623205731c8eb5f22eb5e42
41c1a9d9ce2eeaa47ea2c6286972b3a59dcb7df3
F20110115_AABIKG mcnally_p_Page_038.tif
7f72284cfad34885951ce11aad63d0f3
b6d67c472a0b5dcbd8280946db4e09c32db93ba2
F20110115_AABIJS mcnally_p_Page_023.tif
785f8c4363fed8c5e057ed090b99082e
1d21d4038c31521e3647cba62409274a03ce5443
F20110115_AABIKH mcnally_p_Page_039.tif
0a2a8b80437ee1ae4d233a8b019d177e
ec789de160dad3448147c3e364681136cf0c8509
F20110115_AABIJT mcnally_p_Page_024.tif
0e5a075e092d393f8fe6f03412a3e51f
f860a0ea4e2b43497d9825d2465ffe2314d20220
F20110115_AABIKI mcnally_p_Page_040.tif
31e8d1d78d46cae98a364eb612c3b19e
4e482d181dbe56577c01c59060608a4e49a79913
F20110115_AABIJU mcnally_p_Page_025.tif
90d98f8c065996044f6243b02bbcbdf4
5289643b6561d1c6c1612db1cb70d1a13fd4ab16
F20110115_AABIKJ mcnally_p_Page_041.tif
9d95117fd77e556becbedc42b0407e5f
1a8628895fbda4b6d13247ccecb37618403f832c
F20110115_AABIJV mcnally_p_Page_026.tif
453763443b34c8937120d5cb5f4ba8e4
3790a5783f4ae9f0174b6e9688226e197b41574f
F20110115_AABIKK mcnally_p_Page_042.tif
7208e371ce99f23b468e46dad21d9bac
9359e27bd6dcdddf4df4d4441608245adab2dd12



PAGE 1

THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESMENT IN PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE By PATRICIA A. MCNALLY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2004

PAGE 2

Copyright 2004 by Patricia A. McNally

PAGE 3

To my family.

PAGE 4

iv ACKNOWLEDGMENTS There is no adequate way to thank my children, Jimmy, Meghan and Kerry. for all of their support and love duri ng my doctoral studies. I c ould not have completed this work without their belief in me, the fre quent phone calls, visits, and words of encouragement. Lastly, I hope my grandc hildren may you love and appreciate the educational process with the wonder that I have experien ced throughout my lifetime. I would also like to than k my supervisory committee for their knowledge, guidance and encouragement in supporting me. Esp ecially, I would like to thank Sharleen Simpson, my chair. Her constant patience and guidance and belief that you can do this gave me such support throughout this doctora l process. Additi onally, thanks go to Hossein Yarandi for his valuable assistance in analyzing data, and to Dr. Donald Caton, a teacher and friend, who has been a leader in relieving pain. Through his example, he brings out the best in all of us. Finally, thanks go to Dr. Monika Ardelt who has pursued research that includes the study of spirituality a nd geriatrics. I will al ways be indebted to all of them for their direction. I am grateful to Dr. Peter Gearen, Chai rman, Orthopaedic Department, and Dr. Nik Gravenstein, Chairman, Anesthesia Depa rtment, for their support in designing and implementing this research. Additionally, I want to thank the Pre-Surgical Center administration for supporting the importance of this research and providing access to patients.

PAGE 5

v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES...........................................................................................................viii ABSTRACT....................................................................................................................... ix CHAPTER 1 INTRODUCTION........................................................................................................1 Background and Significance.......................................................................................3 Chronic Pain in the Older Adult............................................................................3 Osteoarthritis and Chronic Join t Pain in the Older Adult......................................4 Total Joint Arthroplasty in the Older Adult..........................................................5 Spirituality in Older Adults...................................................................................5 Summary.......................................................................................................................7 Specific Aims................................................................................................................7 Terminology.................................................................................................................8 2 REVIEW OF THE LITERATURE............................................................................10 Presence of Musculoskeletal Chronic Pa in and Arthritis Among Older Adults........10 The Relationship of Background Contextual Stimuli and Pain..................................11 Age, Pain, and Osteoarthritis...............................................................................11 Gender, Pain and Osteoarthritis...........................................................................12 Age, Gender, and Osteoarthritis..........................................................................12 Race, Pain and Osteoarthritis..............................................................................13 Total Joint Arthroplasty..............................................................................................14 Prevalence............................................................................................................14 Gender and Arthroplasty.....................................................................................15 Race and Arthroplasty.........................................................................................16 Spiritual Coping...................................................................................................16 Spiritual Coping and Health................................................................................18 Relationships between Spiritual Beliefs, Gender and Race................................21 Roy Adaptation Model-Based Research.............................................................22 Roy Adaptation Model Gerontologic Research..................................................23 Summary.....................................................................................................................24

PAGE 6

vi 3 METHODS.................................................................................................................25 Research Design.........................................................................................................25 Controls...............................................................................................................25 Power Analysis and Sample Size........................................................................26 Procedures...........................................................................................................26 Protection of Hu man Subjects.............................................................................27 Method.................................................................................................................27 Measures..............................................................................................................28 Preoperative Questionnaire Measures.................................................................28 Indicator of spirituality.................................................................................28 Indicator of self-h ealth assessment..............................................................28 Indicator of ethnicity....................................................................................29 Postoperative Data Co llection Procedures..........................................................29 Data Analysis..............................................................................................................31 Summary.....................................................................................................................32 4 RESULTS...................................................................................................................33 Sample Characteristics........................................................................................33 Regional Anesthesia............................................................................................34 Anesthesia Technique During Surgery................................................................34 Analysis of Data in Relation to the Hypotheses.........................................................35 Hypothesis 1........................................................................................................35 Hypothesis 2........................................................................................................35 Hypothesis 3........................................................................................................36 Additional Findings....................................................................................................36 The Short Form-36 Health Survey .............................................................................37 5 DISCUSSION.............................................................................................................45 Research Findings.......................................................................................................45 Sample Characteristics........................................................................................45 Impact of Health Assessment and Spir ituality on Pain Reports and Analgesic Medication Use................................................................................................48 Conclusions.................................................................................................................48 Strengths and Limitations....................................................................................49 Implications for Nursing Practice and Future Study...........................................50 APPENDIX A LETTER OF AGREEMENT......................................................................................53 B INFORMED CONSENT 08-19-03 TO 07-15-04......................................................55 C INFORMED CONSENT 01-29-04 TO 07-15-04......................................................63

PAGE 7

vii D INFORMED CONSENT 07-16-04 TO 07-15-05......................................................71 E THE SHORT FORM-36 HEALTH SURVEYSPIRITUAL INVOLVEMENT AND BELIEFS SCALE.............................................................................................78 LIST OF REFERENCES...................................................................................................87 BIOGRAPHICAL SKETCH.............................................................................................92

PAGE 8

viii LIST OF TABLES Table page 1 Frequency and Percent of Variables.........................................................................38 2 Summary Measures of Variables.............................................................................39 3 Pearson Correlation Coefficients-Spi rituality and Variables with No Adjustments..............................................................................................................39 4 Pearson Partial Coefficients-Controlling for Health Assessment............................39 5 Pearson Correlation Coefficients-Health Self-Assessment and Variables with No Adjustments..............................................................................................................40 6 Pearson Partial Coefficients-Health Se lf-Assessment and Vari ables Controlling for Spirituality..........................................................................................................40 7 Frequencies and Percentages for Self Reported SIBS Questionnaire (N=115)......41 8 Frequencies and Percentages Questions that Indicated Ratings for General Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey questionnaire (N=115)..............................................................................................43

PAGE 9

ix Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE By Patricia A. McNally December 2004 Chair: Sharleen Simpson Major Department: Nursing The purpose of this descriptive study wa s to investigate relationships between spirituality and self-heath with three postoperative outcomes after total hip or knee arthroplasty in the older adult. A total of 115 subjects between the ages of 55 and 86 years of age (M = 67.8) who met the inclusion criteria were enrolled in this study. Forty-one were male and seventyfour were female. One question from the Spiritual Involvement and Beliefs Scale and one question from the Short Form-36 Health Survey were used to measure spirituality and self-health assessment. Operative site, av erage daily pain scores, median daily pain scores and analgesic medication use data were obtained from the patient’s medical record for three days postoperatively. Bivariate analysis found that those participants with a high degree of spirituality did not report less pain on days one (r = 0.01, p = 0.92), day two (r = 0.02, p = 0.84) or day three (r = 0.03, p = 0.78). They also did no t use less analgesic medication during the

PAGE 10

x three postoperative days (r = -0.04, p = 0.69). However, those participants who selfassessed their health as good to excellent did have less pain on day one (r = 0.31, p = 0.00), day two (r = -0.29, p= 0.00) and day three (r = -0.22, p = 0.02). There was no reduction in analgesic medication use (r = -0.11, p = 0.25). An ANOVA regression found there was no relationship for a high de gree of spiritualit y, a high self-health assessment and the use of less pain medication (F = 1.04, p = 0.38). The study supported the hypothesis that older adults who rate th eir self-health as good, very good or excellent experienced less postoperative pain but this study did not support less pain medication use. Second, th is research did no t support the hypothesis that a participant’s spirituality influen ces pain or analgesic medication use after arthroplasty surgery. Third, a high degree of spirituality and good health together did not make a difference in the amount of analge sic medication used for pain control. The majority (81.7%) of the participants felt their health was good, very good or excellent. Second, most (67%) indicated they were highly spiritu al and 70% felt that spiritual health contributes to physical hea lth. Finally, the major ity of the respondents believe in spiritual coping behaviors such as prayer, belief in an afterlife and a personal relationship with a greater power. This research found that an individual who rates their self -health as good, very good or excellent has less pain after arthroplasty surgery, bu t this self-health assessment does not influence the use of pain medi cation. Although participants considered themselves “highly spiritual”, their spiritua lity did not influence postoperative pain or pain medication use.

PAGE 11

1 CHAPTER 1 INTRODUCTION The increased number of aging persons ha s stimulated researchers to define the concept of aging as viewed by older adults in our society. Rowe & Kahn, (1998) define successful aging as the avoida nce of disease and disabilit y, social involvement and high level of cognitive and physical function. Succe ss, according to their definition, includes few physical limitations, health, and the absence of chronic pain. Most adults over 55 yrs of age do not report problems with daily activities such as: walking, bending and stooping without assistance. In this age gr oup, however, chronic pain can limit the level of functional activity. A chief cause of chroni c pain and disability among adults over 55 is osteoarthritis The experience of chronic pain in the el derly is both a physiologic and emotional experience. Although rooted in sensory stimu li, pain also has an important overlay from an individual’s culture and e xperience (Porter, et al. 1996). Among all age groups pain can be defined as an experience with both a sensory and emotional component, but for the elderly adult, pain may signify a chr onic condition that is not always managed effectively with drug treatment. The most frequent cause of chronic pain and total disability reported by the ol der adult is arthritis (Aff leck, et al. 1999; Felson, 1988; Mobily, Herr, Clark, & Wallace, 1994; Praem er, Furner & Rice, 1999; Schlesinger, 2001). The American Geriatrics Society su ggests using both pharmocologic and nonpharmocologic methods to achieve a greater de gree of pain relief (American Geriatrics

PAGE 12

2 Society, 1998; Gagliese & Me lzak, 1997). Non-pharmocologic methods of pain control include massage, acupuncture, and behavioral ther apy. Keefe, et al. (2000) in a study of rheumatoid arthritis and joint replacement, f ound that effective coping strategies included praying, hoping and calming self-statements. Research on the relationship of spiritualit y and health has gained increasing interest in the academic and popular press over the pa st 15 years. Most early research used retrospective data analysis to study the eff ects of religious affili ation, and hypertension, depression, mortality, and anxi ety (Clark, Friedman, & Mart in, 1999; Husaini, Blasi, & Miller, 1999; Koenig, George, Blazer, Prit chett, & Meador, 1993; Koenig, George, Meador, Blazer, & Dyck, 1994). They obser ved a positive correlation between church attendance and various correlates, such as hypertension, depression, anxiety, hospital length of stay, and mortality (Koenig, et al. 1993; Koenig & Larson, 1998; Meador, et al.1992). Levin and Chatters (1998) suggest fu ture quantitative studies to evaluate relationships between spiritu ality and health. Although older people may rely more on defensive coping strategies, the possibility th at spiritual coping mechanisms may have a therapeutic effect has not been explored. Such spiritual coping mechanisms might include prayer, religious serv ice attendance, and seeking a spiritual connection (Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, Smith, Koenig, & Perez, 1998). These studies suggest that older adults who use spiritual c oping methods during stressful medical conditions have a more positive health outcome. I wished to explore the effect of spiritual belief, spiritual behavior and health selfassessment on the response to postoperative pain. Towards this end I examined the

PAGE 13

3 relationship between specific as sessments of spiritual behavior health self-assessment, to reports of pain report and the use of analge sic medications among a group of older adults recovering from hip replacements surgery. Background and Significance Chronic Pain in the Older Adult Pain is defined as a noxious physical and emotional experience. Although similar for all age groups, elderly adults appear to have a higher incidence of chronic pain. The only measure of the presence and intensity of pain is the re port of the person experiencing the pain (Ferrell, 2000). Noci ceptor pain, including chronic pain, begins with the activation of special receptors and afferent fibers by peri pheral stimuli usually associated with processes involving tissu e damage and inflammation (Ekblom & RydhRinder, 1998). Such pain may include musculos keletal pain, ischemic pain, visceral pain, and myofascial pain. There is little empirical evidence that biological or physiological measurements correlates to the degree of pain expressed by th e elderly individual (Gagliese & Melzack, 1997). In other words, to a large extent the ‘exp erience’ of pain is subjective. Among the elderly, research indicates that mo re than 90% of the elderly experience pain in the musculoskeletal system (Ande rson, Ejlertsson, Lenden & Rosenberg, 1993). Chronic arthritic joint pain begins in the upper extremities such as shoulders and then progresses to the lower extremity as an indi vidual ages (Anderson, et al. 1993; Mobily et al. 1994). This site of the pain can greatly affect severity of chr onic pain as well as the degree of functional impairment.

PAGE 14

4 Osteoarthritis and Chronic Jo int Pain in the Older Adult Osteoarthritis is the most frequent cause of end stage joint dete rioration and chronic pain in the elder adult. In the early stage, there is only a pathologic loss of cartilage. As the disease advances jo int cartilage and underlying bone are affected, with a total loss of cartilage and joint space. Joint cartilage serves two functions: 1) smooth frictionless surface movement of articulating bones, and 2) transmission of the weight bearing load. Additionally, extensive tissue inflammatory changes surround the affected joint and contribute to the limitation of joint range of motion and severe chronic pain (Schlesinger, 2001). Visible osteophytes or la teral outgrowths of bone in th e joint margins add to an increased sclerosis of underlying bone that contributes to an additional increase in functional impairment (Felson, 1988; Schlesinger, 2001). This loss of the articular cartilage can be demonstrated radiogra phically as a joint space narrowing and occasionally, osteophyte formation. The most frequently affected joint locations are knees, hips, fingers, and sp ine (Praemer, et al. 1999). Measurement of the impact of arthritis includes two parameters: disability or functional impairment and economic health car e system impact. The adult person 65 years of age with arth ritis may have more limitations of activity than those afflicted with other chronic disease states such as cardiac disease, diabetes, and cancer. It has been estimated that 50% of those persons 65 y ears of age and older experience activity limitation from the chronic pain of osteoarthr itis (Mobily, et al. 1994). The failure of conservative medical management, such as medications and physical therapy, in the treatment of end stage joint osteoarthritis, has increased the demand for surgical total joint replacement.

PAGE 15

5 Total Joint Arthroplasty in the Older Adult The early 21st century has been declared the “Bone and Joint Decade” by 35 nations and 44 states. Currently, more than 425,000 to tal joint replacements are performed each year in the United States, and this number is expected to reach 702,000 by the year 2030 as the baby boomer generation ages (Praemer, et al. 1999). The increase in the number of aging Americans, the increase in the prevalen ce of arthritis for this age group, and the desire to remain active have added to the increase in demand for total joint replacement surgery (Healy, Iorio, & Lemos, 2001). Join t replacement surgery has been documented to improve pain, functional ability, social f unction, and quality of life for the recipient (Aarons, Hall, Hughes, & Salmon, 1996; McGuigan, Hozack, Moriarty, Eng, & Rothman, 1995; Norman-Taylor, Palmer, & V illar, 1996; Ritter, Albohm, Keating, Faris, & Meading, 1995). These findings demonstrate that osteoarthr itis among older adults is a major cause of chronic pain and functional impairment. To tal joint replacement offers the older adult pain relief and improved functional ability, pa rticularly when there is failure with conservative therapies. Spirituality in Older Adults Behavioral management of pain includes the strategy of active coping. Spiritual coping behaviors that include praying and church attendance have been recognized as active coping behavioral strategies used often by older adults (Koenig, et al. 1998). Burkhardt, (1989) defines the “spirituality” as the individual’s belie f in God or a higher power that is concerned with his or her stri ving to achieve a sense of harmony with self and others. Spirituality often involves a re lationship with an organized religion, interrelationships with others, and the search for the meaning of life. Affiliation and/or

PAGE 16

6 participation in organized religion, however, ar e not necessary to be considered spiritual (Burkhardt, 1989; Principe, 1983) Different authors have defined ‘spirituality’ in various ways. For the purpose of this discussion, I will use the “spirituality” to describe the way of life an individual chooses that involves a belief in G od or a higher power, a belief in an after life, and a belief that a hi gher power influences life’s events. I did not limit this study to ‘spirituality’ associat ed with any specific religion or sect. There has been an increasing interest in the interrelationship of spiritual involvement, spiritual activity, and health outcomes among the elderly. Koenig, McCullough, and Larson (2001) give three reas ons for this current interest. First, spirituality and religious affiliation continues to be a central part of people’s lives despite advances in technology, education, and medici ne. Second, the United States and other worldwide populations are aging due to a dec lining birth rate and gr eater longevity. In the future, social programs will have severe financial hardships in providing services for this population and religious groups may assist in providing some of these services. There is the possibility that spiritual coping may aid in the prevention of health problems and thereby assist in health car e cost containment. Finally, there is a depe rsonalization in the health care delivery system. Individua ls seeking medical care and treatment expect compassion with attention to their social, psychological, and spirit ual needs. McFadden and Levin (1996) summarize recent gerontologi c spiritual research as focusing on four areas of interest: “(a) multidimensional measures, (b) patterns, (c) predictors, and (d) psychosocial and health relate d outcomes of religious involv ement in older adults and across the life course” (p. 350).

PAGE 17

7 Summary Many disciplines including medicine, psychology, and sociology have examined the relationship of coping and religious affiliation; coping and spiritual beliefs; religious attendance, and health outcomes like pain, depression, quality of life, mortality, and morbidity. This investigator believes that th e degree of spirituality in the post-surgical older adult patient has not been considered in evaluating pain report and analgesic medication use. Achieving adequate pain cont rol is a major goal of professional nursing care and utilizing spiritual coping may be an important addition in providing nonpharmocologic pain management. Specific Aims The purpose of this study is to explore whether a high degree of spirituality, and high scores for self-health assessment are correlated with postoperative pain and analgesic medication use in the acute hospita l recovery phase. Currently, there is no evidence in literature that has examined thes e variables and their relationship with the use of postoperative pain medication after total joint arthroplasty. Prior research focused on relationships of long-term f unctional rehabilitation, quality of life and spiritual coping. Using two multidimensional instruments, I propos e to address three important aims that will contribute to the relationship of spirituality, self-health assessment, pain report and analgesic medication use in the postoperative older adult joint ar throplasty patient. First, using a multidimensional instrument this study will investigate whether a high degree of spirituality is associated with less pain report and medication use in older individuals receiving primary hip or knee arthropl asty for osteoarthritis. It is the aim of this research to determine whether older adul ts receiving a hip or knee arthroplasty with a

PAGE 18

8 high score for spirituality on the Spiritual I nvolvement and Beliefs Scale (SIBS) will use less analgesic medication postoperatively. Second, the Short Form-36 Health Survey th at measures general health assessment will be used to measure self-health in this re search. It is the aim of this research to determine whether older adults with a high sc ore for health self-assessment will use less analgesic medication after c ontrolling for spirituality. Finally, the responses for both spiritual ity and self-health together will be correlated with analgesic medication. Hypothesis 1. Older adults with a higher degree of spirituality receiving a hip or knee arthroplasty for primary osteoarthritis wi ll report less pain and receive less analgesic medication than those participants with a lower degree of spirituality after controlling for health self-assessment. Hypothesis 2. Older adults with high scores on the self-health assessment tool will report less pain and receive less analgesic me dication than those pa rticipants with low scores on the self-health assessment t ool after controlli ng for spirituality. Hypothesis 3. There will be significantly le ss analgesic medication used by those older adults receiving hip or knee arthroplas ty who have a high degree of spirituality, and a high degree of self-health assessment. Terminology Older adult : Age 55 or older Epidural : Medications administered to the epidural space su rrounding the spinal cord. Extrinsic religious orientation : The pursuit of religious beliefs and religious practice to feel protected or gain ing social status and approval.

PAGE 19

9 Femoral Nerve Sheath : Medication administered within the femoral nerve sheath by means of a catheter to anes thetize the femoral nerve. Intrinsic religious orientation : The motivation to live the goals set forth by religious tradition. The way of life often described as “living one’s religion” and using religious practices. Th e person who has an intrinsi c religious orientation may not be affiliated with a pa rticular religious group. Medication Administration Record (MARS) : Individual record of medication administered to a patient during inpatient hospitalization. Each dose of medication is recorded with the following data: me dication name, dosage, time administered, name of staff administering medication. Opioid equi-analgesic conversion : All narcotic medication was converted to Morphine Sulfate IV equivalents. Patient controlled analgesia : Self-administered narcotic analgesia through an intravenous infusion. Religious affiliation : Participating in an organized religious group Spirituality : The way of life an individual chooses to live that inte rnalizes a belief in a higher power. These life thoughts ar e separate from the body and may involve God, a belief in an afterlife, and belief that this highe r power influences life’s events. Spiritual behaviors : Praying, meditation and/or self-reflection, reading spiritual writings Visual Analog Scale (VAS) : A pain rating scale adopted by Shands at the University of Florida to provide accuracy in a patient’s pain. The scale is numeric, one = no pain and 10 = the worst pain of life. Patients are asked to rate their pain using numeric increments 0 to 10.

PAGE 20

10 CHAPTER 2 REVIEW OF THE LITERATURE This section deals with pertinent papers published during the past 20 years that address chronic pain, osteoarthritis, lower ex tremity arthroplasty, and spirituality coping among the elderly. The first section examines the prevalence of the chronic pain of osteoarthritis and arthroplasty (focal stimuli) age, gender, and race (contextual stimuli). The second reviews the relations hip of spiritual coping to ge nder, race, age, and pain. Presence of Musculoskeletal Chronic Pa in and Arthritis Among Older Adults Pain in the aged adult has become a fo cus of current gerontologic research. The elderly have more painful diseases that re quire more medical visits. The impact of musculoskeletal conditions on th e elderly can be divided in to two categories: 1) the physical and social impact of physical pain (lim itations in mobility and social interaction imposed by these limitations), and 2) the mone tary cost involved in the diagnosis and treatment of these disorders (Praemer, Furner, & Rice, 1992). Musculoskeletal disorders after age 65, regardless of gender or racial group, are th e most frequently reported physical impairments, exceeded only by hearing disorders. Surgical intervention, following failed medical management, is expect ed to increase dramatically in the next twenty years (Praemer, et al.1999). Mu sculoskeletal functional limitation has a significant impact on the elderly. Back and spine disorders are the most fr equently reported category of dysfunction, followed by lower extremity disorders of th e hip or knee. Although there are many forms of arthritis among the elderly, th e two most common forms, thos e with the greatest public

PAGE 21

11 health implications, are osteoarthritis and rheu matoid arthritis. The more prevalent of the two forms, osteoarthritis, is estimated to affect 20 million people in the United States (Praemer, et al.1999). The Relationship of Background Contextual Stimuli and Pain Age, Pain, and Osteoarthritis Anderson, et al. (1993) found that 90% of individuals surveyed experienced chronic musculoskeletal pain. Chronic pain symptoms increased between ages 50-64 and then gradually declined. After age 60, howev er, the incidence of lower extremity pain increased. Compared to younger adults, lowe r joint pain doubled after age 65 (Anderson, et al. 1993; Gibson & Helme, 1995). In the Io wa study, Mobily, et al. (1994) observed a lower incidence of overall pa in (p< .0001) among those over 85 years compared to younger age groups. They also found more than 86% of those surveyed experienced pain longer than 12 months. Their research is felt to be particularly accurate because of their large sample size and the longitudinal study design. Several studies have examined the influe nce of age on pain sensitivity. Gibson and Helme ((1995) examined sensitivity to several different forms of experimental pain using a meta-analysis. Their data suggest a decl ine in thermal sensitiv ity after age 60, but do not show a conclusive difference, or change, in pain sensitivity or pain tolerance. An earlier study by Helme and Allen (1992) had f ound that the majority of those surveyed (79%) agreed that pain was a consequence of the aging proce ss. However, less than half of these older adults reported pain. The authors concluded th at older adults expected to experience pain as they aged and they did.

PAGE 22

12 Additional research is needed to evalua te both the physiologic and psychological basis for pain among older adults. More effec tive management of pain in the older adult originates in a better understanding of differences and si milarities in the pain response. Gender, Pain and Osteoarthritis Experimental research has not demonstr ated a conclusive difference in pain perception related to gender. Using heat as a noxious stimulus in humans Paulson, Minoshima, Morrow, and Casey (1998) conclu ded there was a gender similarity in the cerebral and cerebellar activati on, but anticipation of the stim ulus was more intense in females. Keefe, et al. (2000) measured pain, disa bility, and pain behavior among men and women with a mean age of 61.1 yrs. They re ported significant gender differences in pain intensity, pain behavior, and phys ical disability associated wi th osteoarthritis. Women had significantly elevated levels (F (1,166) = 4.41, P <0.05) of osteoarthritis pain. They measured pain behavior, which included s tiff movement, rubbing affected joint, and flexing the joint, in relation to gender. In their analysis women exhibited more pain behavior than men (F (1,162) = 5.54, P < 0.05). In a recent study of pain and coping, Affleck et al. (1999) observed that women re ported daily osteoarthritis pain and pain levels 73% greater than males with a similar arthritis diagnosis. Re sults of these studies have suggested that among the elderly, there is a difference in pain intensity related to gender. Further research is n ecessary to compare noxious pain stimuli, pain thresholds and intensity studied in younger pop ulations to the older adult. Age, Gender, and Osteoarthritis Compared to males, females have twice th e incidence of osteoarthritis. Until age 65, however, men report a greater occurrence of osteoarthritis. While men are more

PAGE 23

13 likely to have shoulder, elbow and foot join t pain; women have finger, hip, ankle and wrist joint pain (Davis, E ttinger, Newhaus & Hauck, 1987). Although specific affected joint patterns have been identified as following a gender pattern, gender differences do not contribute to risk factors for the deve lopment of osteoarthr itis (Davis, et al. 1987;Keefe, et al. 2000; La wrence, et al. 1998). Race, Pain and Osteoarthritis Differences in cultural response to pain have been studied using two methods, nonexperimental using observational methods, a nd laboratory experimental using painful stimuli and measuring the response. Zatz ick and Dimsdale (1990) were unable to correlate cultural variations in pain response in their meta-ana lysis of pain stimuli and of pain response. They concluded, “there is no evidence suggesting that the neurophysiology detection of pain varies acr oss cultural bou ndaries” (p.554). However, Bates, Edwards, and Anderson (1993) usi ng observational methods to evaluate the differences in reported chronic pain inte nsity among seven diverse ethnic groups, found significant correlations. Add itionally, they investigated specific sociodemographic, medical, and psychological variables that may predict an intra-ethni c group variation in pain intensity. Bates, et al. (1993) found th at pain intensity did not vary among various ethnic groups because of differences in neurophysiology but was a result of the biocultural model of pain perception. European whites have a greater incidence of osteoarthritis than Jamaicans, Blacks, South African Blacks, Chinese, and Indians (Felson, 1988). Rates for American Indians are intermediate. There is speculation that individuals of European white descent have a genetic developmental defect in both the knee and hip joints that facilitates the

PAGE 24

14 development of osteoarthritis. This is s upported by greater reporti ng of joint pain in whites when compared to blacks or other races (Praemer, et al. 1992). Total Joint Arthroplasty Prevalence The first decade 21st century has been declared the “Bone and Joint Decade” by 35 nations and 44 U.S. states. The number of lower extremity joint procedures has increased; total knee replacements incr eased 40.2% during the years 1990 and 1996, while total hip replacements increased 15.5% for the same years (Praemer, et al. 1999). Currently more than 425,000 total joint replacem ents are performed in the United States, and this number is expected to reach 702,000 by the year 2030 as the baby boomer generation ages (Praemer, et al. 1999). The leading reason for joint replacement surgery in the elderly is failure of conservative medical treatment for end stage arthritic joints. The increase in the number of aging Americans, and the increase in prevalence of ar thritis for this age group along with a strong desire to remain active have c ontinued to increase the demand for total joint arthroplasty (Healy, Iorio, & Le mos, 2001). Joint replacement surgery has been shown to improve pain, functional ability, social functi on, and quality of life (A arons, et al. 1996; McGuigan, et al. 1995; Norman-Taylor, et al. 1996; Ritt er, et al. 1995). The goal of total joint arthr oplasty is to recreate the motion of flexion, extension, adduction, and rotation of the joint that has lost range of motion. This surgical intervention demonstrates a ten-year success rate for 98 % of elderly individuals while relieving joint pain and correcting the joint deformity. For patients with bilateral knee joint end stage arthritis, bilate ral joint replacements are often performed at the same time (Pellino, Preston, Bell, Newton, & Hansen, 2002).

PAGE 25

15 Total hip arthroplasty (THA) is a surgical procedure that replaces a diseased joint with a synthetic joint using a synthetic acetabulum, femur, an d polyethylene liner that are fixed to bone by cement or bone ingrowths. Total knee arthroplasty (TKA) involves replacing the femoral and tibia sides of the joint using a l ong or short stem fixated by cement. The goal of joint arthroplasty is to improve function with an artificial joint that improves range of motion and provides pain relief with few surgical complications (Brander, Mullarkey, & Stulberg, 2001). Th e decision making process in considering a candidate for total joint replacement is the degree of radiographic changes and the degree of functional impairment. Gender and Arthroplasty Although women have 1.5-2.0 higher inciden ce of osteoarthritis, men have more total knee arthroplasty than wo men. Katz, et al. (1994) sugge sts that gender differences in joint arthroplasty are difficult to evaluate because procedure rates are not reported by severity of disease. The aut hors evaluated functional status using a daily living scale that evaluates the ability to walk several blocks, climb stairs, or take part in vigorous activity. Greater functional impairment and the use of walking support were reported for most of the females. The authors suggest that ma les have earlier surg ical intervention for functional impairment and pain. Praemer, et al. (1999) do report that the number of total knee replacements for men in 1996 was 1318/100,000 while for women in the same year it was 928/ 100,000. There is some evidence that suggests women delay surgical intervention out of fear of surgical failure, death or loss of function postoperatively. Postponing surgical intervention can also be because of distrust of physicians and hospitals, a reluctance to take risks and concern about caregivi ng responsibilities.

PAGE 26

16 Conversely, males most reported concern is th e length of rehabilitation time necessary for the return of joint function (Ritter, et al. 1995). Race and Arthroplasty The relationship between race and arthroplas ty has been poorly studied. A recent study in a large county in Texas reported that Hispanics were under represented as recipients for hip replacement surgery (Escalante, Espinosa-Morales, Del Rincon, Arroyo, & Older, 2000). In their research, Afri can Americans were also less likely than Caucasians to receive arthroplasty surgery. Extensive review of re search literature on race and arthroplasty, however, revealed no evidence to suggest a disparity in race and arthroplasty. In summary, the number of total joint repl acements increases dramatically for both sexes after age 65 (Praemer, et al. 1999). The effect of this increase can be directly attributed to the incidence of joint osteoart hritis, chronic pain and functional impairment (Felson, 1988; Schlesinger, 2001). Women repor t greater functional impairment for all activities of daily living and de lay arthroplasty for a longer pe riod of time. It is unclear from previous research reasons for gender diffe rences in osteoarthrit is incidence or the delay for surgical intervention. Previous rese arch only verifies the age related changes of osteoarthritis, functional impairment and the increase in total joint replacement surgery for the relief of pain and improvement in physical function. Spiritual Coping According to Lazarus, DeLongis, Folkman, and Gruen, (1985), “efficacy expectations and appraisals refer to cognitions : fear and distress refe r to emotional states that includes cognitions” (p. 776). Stress is regarded as a complex variable and the individual in his/her persona l environment reflects the proc essing of these variables.

PAGE 27

17 Good health and the absence of chronic pain represent a person’ s stable environment. An individual’s inability to maintain these e nvironmental variables creates stress and fear. Through evaluating the stressors and using defense strategies a coping process will be used to overcome the disruption in a pers on’s environment (Lazarus et al, 1985). The older adult uses cognitive interp retation to identify stressful h ealth changes and uses more defense strategies to cope. Diehl, Coyle, and Labouvie-Vi ef, (1996) found that compared to younger people; there was a difference in the use of self-restraint by older adults rather than aggression to cope with environmental stressors. Religious behaviors such as prayer, re ligious service atte ndance and seeking spiritual connection, are part of the individual’s practice of sp iritual or religious coping (Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, et al. 1998). Researchers have studied the various spirituality concep ts: 1) Religious doctrine; 2) Religious attendance; and 3) Religious affiliation. Spirituality includes both the world of experience and the way of life a person lives that is guided by religious doc trine (Principe, 1983). It is the continuous process of integrating oneself in current and past experien ce and the effort of re lating to others with trust and understanding. Spirituality links self with a pow er greater than the individual. It is most often associated with a religion that defines the divine and offers ways to relate to the sacred (McFadden & Ge rl, 1990). Fowler describe s the persons life spiritual development as a developmental psychological process that uses cognitive and emotional synthesis of a sense of meaning and pu rpose in the life jo urney (Shulik, 1988). Interest in research involving the relations hip of spirituality and health has been increasing over the past 15 years. Most existing research has focused on religious

PAGE 28

18 affiliation and health status in hypertension, depression, mortality, and anxiety (Clark, Friedman, Martin, 1999; Husaini, Blasi & Miller, 1999; Koenig, et al. 1993, 1994). The examination of a possible therapeutic effect of spirituality in the postoperative joint replacement patient has not been explored. Levin and Chatters ( 1998) suggest that in order to establish a relationship between sp irituality and health, research must use evaluate a measurable medical effect of spirituality or relig ion and aging. This research will hypothesize that a positive relationship does exist between the older adult’s degree of spirituality and self-health assessment. Spiritual Coping and Health There has been no published research demonstrating a relationship between spiritual coping, health assessment, and post-su rgical pain. Most empirical research has focused on the relationships of spiritual copi ng, spiritual beliefs, spiritual involvement and health outcomes in mental health, hypertension, depression, and anxiety. Matthews, et al. (1998) reviewed the re lationships of religious fact ors that included religious attendance and mental health status. The focal areas of mental health status were coping and recovery from illness. The authors c oncluded in their review there was strong support for religious commitment and positive medical outcomes following serious illnesses e.g. heart disease, cancer. Pargamen t, et al. (1998) using a spiritual well being scale found there was a relationship between positive and negative patterns of religious coping in young and elderly age groups. Th ey measured three di verse sample groups experiencing stressful life events. The firs t sample represented Oklahoma City residents who were evaluated for religious coping afte r the federal building bombing. The second sample involved college students who had experi enced a significant negative event, such as a death of a friend or family problems. The third sample group was hospitalized

PAGE 29

19 patients over the age of 55 with moderately severe medical illness. Although, the participants were of differen t ages and diverse life event stressors, a posi tive pattern of religious coping was found among the three gr oups. Those particip ants with positive religious coping patterns had less psychological anxiety and di stress. Those individuals with negative religious copi ng were associated with great er emotional distress, e.g. depression, and reported poorer quality of life. Pargament and colleagues (1990), extended their religious coping re search to more clearly identify the kinds of religious beliefs, and behaviors that ar e helpful to individuals as they cope with negative life events like death, illness, divor ce and work related problems. Four separate themes of religious beliefs and behaviors emerged to furthe r define spiritual beliefs and practice: 1) belief in a fair and loving God; 2) part nership with God is supportive; 3) positive outcomes come from using of re ligious rituals; and 4) sear ch for spiritual and personal support through religious affiliation. Pargamen t, et al. (1990) explains nonreligious avoidance with descriptor items from personal narratives such as “tri ed not to think about it,” “wished the situation would go away” (p. 818). Using retrospective demographic data coll ection, early research that focused on religious affiliation and hea lth status demonstrated pos itive relationships between religious affiliation and various health co rrelates, such as hypertension control, depression, anxiety, length of hospital stay and mortality (Koe nig, et al. 1993; 1998; Koenig & Larson, 1998; Meador, et al. 1992). In a review of 20 empirical studies, Levin & Vanderpool (1990) concluded that religion is therapeutically beneficial in the control of hypertension. Koenig, et al. (1998) investigat ed the relationship of religious activities and blood pressure control among older adults dwelling in communities. They concluded

PAGE 30

20 that religiously active adults displayed lower blood pressures and were more compliant with prescribed medication. Additionally, they observed a racial difference. The authors found that although black religious males had higher blood pressures than white religious males, they were more compliant with me dication use for blood pressure control. Recent research has examined spirit uality and functional ability during rehabilitation. Kim, Heinemann, Bode, Sliwa, & King (2000) examined spirituality using an intrinsic Judeo-Christian scale of wellbeing and functional va riables among patients in a rehabilitation hospital. Intrinsic re ligiousness is define d as the individual’s internalizing a religious belief and living the belief. Individual spir ituality scores though high were not associated with variables of f unctional recovery such as mobility, and selfcare. Fitchett, Rybarcyk, DeMarco, and Ni cholas (1999) found similar results in postoperative rehabilita tion. There was a high degree of spir ituality among their patients who rated their health as poor or very poor. Using a questionn aire that measures church affiliation, attendance, and spir itual behaviors, the author s were unable to confirm a relationship between self-health assessment, spirituality, and church activities. Pressman, Lyons, Larson, and Strain (1990) in a small study of postoperative female orthopedic patients found significant correl ation between church attendance, person al importance of religion, degree of spirituality, and functiona l meters walked (r=0.45, df = 27, p<0.05). This research found that post operative orthopedic subjects wi th strong religious beliefs and practices, and less depression had better ambulatory function at discharge. The spirituality score was not significantly correla ted with ambulatory status independent of depression. The authors suggest that subjects who are spir itual respond more favorably to physical therapy because they are less depressed. Hodges, Humphreys, and Eck

PAGE 31

21 (2002) investigated the effects of spiritua lity on spinal surgery recovery. Using a spirituality tool that evaluate s intrinsic spirituality, they found these subjects to be highly spiritual (79%). The authors then compared preoperative and postoperative pain scores with postoperative functional ability. They found no correlation between a high degree of spirituality and pain scor es or functional outcomes. Spiritual research has investigated the po ssible relationships of pain, health and functional recovery. In each study, older adults have a hi gh degree of spirituality on various measurement tools, but only one st udy reported a significant correlation that included a finding of less depres sion. The investigation of sp irituality and health has not been evaluated using consistent measures of spirituality scales and postoperative population groups. Most current research has observed possible religious affiliation, spiritual beliefs and functional status. Relationships between Spiritual Beliefs, Gender and Race Few empirical studies have examined pa in, gender, and racial relationships (Affleck, et al.1999). Research regarding utiliz ation of health services demonstrated a positive correlation between utilization and religious attendance in elderly male patients 60+ years of age. Increased attendance at religious services prior to hospitalization correlated with a shorter hospital stay and fewer hospital admissions (Koenig & Larson, 1998). Past research concentrated on religiou s coping behaviors, including religious affiliation, beliefs and involvement. Research fi ndings suggest that many older adults use spiritual coping in various st ressful health situ ations and that this coping has had a beneficial effect. Further investigation is n eeded using spiritual measures to examine if

PAGE 32

22 there is a spiritual coping adaptive effect in the management of older adult postoperative pain. Roy Adaptation Model-Based Research In 1976, Sister Callista Roy’s theory of an adaptation model for nursing was presented to guide nursing edu cation in the United States. The theory was later revised to address the middle range or practice level theo ry relevant to patient care in nursing. In 1999, a new model of the Human Adaptive sy stem was introduced to clarify the understanding of the various components of th e theory and to extend it into clinical practice (Roy & Andrews, 1999). Roy define s the purpose of nursing practice as the promotion of the ability of hu man adaptive systems to adjust effectively to changes in the environment and to the individual’s abil ity to modify their environment (Roy & Andrews, 1999). Roy’s theory contains scie ntific and philosophical assumptions that describe successful human coping in cha nging environments. According to Roy, the adaptation of the human system is based on scientific assumptions that include: 1) meaning is necessary for person and environmen t integration; 2) thinking and feeling is necessary for awareness; 3) people have a co mmonality of patterns and relationships; 4) adaptation results from the integration pe ople and their environment. Further, the adaptation concept includes Roy’s philosophical assumptions: 1) relationships include a higher power and the world; 2) people use the ability of faith; 3) God is observed in diversity of crea tion, and is the destiny of creation.

PAGE 33

23 Figure 2-1. Model Diagram of Research Questions Roy Adaptation Model Gerontologic Research Roy describes the adaptive process as adjusting effectively to environmental changes using cognitive interpretation and c oping processes to maintain an integrated life. In this model, compensatory life pr ocesses are spiritual coping and health selfassessment. These regulatory processes pr ovide an adaptive re sponse for less pain. Roy’s adaptation model has been used mainly with children and adults in a hospital environment. One gerontologic study has us ed the Roy adaptation model to evaluate a coping process and the concept of self-consistency. Roy belie ves the concept of personal self is a combination of self-consistency, the moral-ethical spiritual self and the self-ideal (Roy & Andrews, 1999). Zhan (2000) us ed the Roy Adaptation Model to study adaptation and coping with severe hearing lo ss in 130 elderly adults Health status and coping data were analyzed for positive rela tionships between cogni tive coping and self-

PAGE 34

24 consistency. There was a positive correlati on between those who ra ted their health as good or excellent and self-consistency. The va riance in self-consiste ncy was the result of cognitive coping processes. Three cognitive processes; clear focus and method, knowing awareness, and self-perception were mo st significant (36.97 (p< .001, df =5). There is support for the use of the Roy Adaptation Model in gerontological research to evaluate spirit ual coping and adaptation to pa in. Successful adaptation to environmental changes is necessary to return to good health and well being as people age. Summary Chronic pain in the aged adult is both a physical and emotional experience. Current research suggests that the use of pharmocologic and non-pharmocologic methods in the elderly may reduce chronic pain. Howeve r, some research findings suggest that the use of specific non-pharmocologic interventions such as spiritual behavior, religious attendance, and spiritual beliefs are inconclusi ve in providing relief from the negative effects of chronic illness and pain. This research study will evaluate relationships between spirituality and analgesic medication us e after total joint arthroplasty in older adults. Measurement of the degree of spirituality a nd health will evaluate the effectiveness of coping with postoperative pa in in the older adult. Th is research will provide quantitative data to provide a framework for evaluating older adult’ s spirituality as an alternative non-pharmocologi c intervention in postopera tive pain management.

PAGE 35

25 CHAPTER 3 METHODS Research Design This research examines the relationship of older adults’ spiritual beliefs, and selfhealth assessment and analgesic medication use during the first three days after total joint replacement surgery. A correlational conveni ence design was used to investigate the questions in a sample of surg ical candidates scheduled for hi p and knee joint arthroplasty. Using the Roy Adaptation Model, this study ex amined relationships between total joint arthroplasty for osteoarthritis chronic pain, the degree of spiritual beliefs, spiritual involvement, self-health assessment and the health outcome of postoperative analgesic medication use. Participants for this research came from a socially diverse area in North Florida. Controls Three orthopedic surgeons from the Univ ersity of Florida College of Medicine, Department of Orthopedics performed all of the total joint arthr oplasty. To control variations in general anesthes ia technique, one supervising an esthesiologist planned each participant’s anesthetic ca re. Participants chose hi s/her preferred method of postoperative pain control prior to surgery. Choices included regional anesthesia, Patient Control Analgesia (PCA), or PRN dosing. Preo perative patient education and anesthesia evaluation was done according to the standard of care establ ished by the University of Florida College of Medicine.

PAGE 36

26 Inclusion criteria: 1. 55 years of age or older 2. Primary hip or knee joint arthroplasty 3. Osteoarthritis of the hip or knee joint as demonstrated by radiographic exam and orthopedic surgeon’s diagnosis as documented in the medical record 4. Failed medical management of chronic joint pain 5. Inclusion regardless of comorbidity status 6. Candidates for hip or knee arthroplasty Power Analysis and Sample Size An estimate of statistical power was determined using the G power computer software to calculate the required sample size. A total of 115 participants were consented and completed the study. The sample size wa s based on a formulation of 80% power, at least six independent variables, an e ffect size of 0.15 (R-s quared= 0.13) with a significance of 0.05 for a two-ta iled test. The G power comput er software was used to calculate the required sample size (Erdfelder, Faul, & Buchner, 1996). Procedures The Principle investigator of this study contacted the chairman of the Orthopedic Department and presented a description of the study. The chairman then provided a signed letter of agreement acknowledging aw areness of this study (See Appendix A). In the original protocol, I planned control variation in surgical technique using only patients scheduled with one orthopedic surgeon. A total of 27 patients were enrolled from July, 2003 until January, 2004. During this enrollment period, however, the identified surgeon reduced the number of tota l joint surgeries he performed per month in order to fulfill administrative duties. In January, 2004, the investigator met with committee members to explore adding two additiona l surgeons in order to attain within a

PAGE 37

27 reasonable length of time a number of subject s months adequate fo r a power analysis. After appropriated discussions, two additional orthopedic surge ons agreed to help. They were each provided a copy of the protocol and informed consent. A revision that included the two additional orthopedic surg eons was submitted and approved by the IRB in January, 2004. Protection of Human Subjects University of Florida Institutional Review Board (IRB) approval was obtained prior to participant enrollment or data collecti on (See Appendix B for final approval, revised approval and extension approval forms). A re vision to include the additional orthopedic surgeons was submitted and approved in January, 2004. A final IRB extension was submitted June, 2004 to extend the research study from July, 2004 until July, 2005. Method Patients scheduled for surgery are scheduled in the pre-surgical center for an examination by an ARNP to determine their su itability for anesthesia. From this group the principal investigator identified pote ntial subjects for stud y. Subjects who met the inclusion criteria and agreed to participate in the study were given a verbal description of the study, confidentiality assura nce, and possible risks of their participation. Those patients who expressed willingness to participate completed two questionnaires. The questionnaires took approximately 20 minutes to complete during their pre-operative visit. The principal inve stigator and each subject signed a copy of the informed consent. A copy of the signed informed consent was gi ven to the participant for their individual records. The principal investigator verbal ly asked each subject if they had additional questions regarding their particip ation in this research study prior to their discharge from the pre-surgical center.

PAGE 38

28 A key containing the participant’s name, and confidential code was developed. Informed consents and questionnaires were c oded with the participant’s confidential code and are kept in a locked file cabinet in the principal investigator’s office. Measures Demographic data Age, gender and ethnicity we re coded using a coding key (see Appendix G). Demographic data was entered on an Excel spreadsheet after enrollment. There was no missing demographic data. Preoperative Questionnaire Measures Indicator of spirituality The Spiritual Involvement and Belief S cale(Revised (SIBS-R) Hatch, Burg, Naberhaus, & Hellmich (1998) evaluates a broa d range of intrinsic spiritual content from ability to find meaning in life to spiritual writings. Designed for us e with individuals of all religious and non-religious traditions that include Ch ristian, Judeo, Hindu, Islam and Atheist. This instrument differs from other spiritual measurement tools in that it is not limited to individuals with a Judeo-Christian tradition. For the purpose of this study one question was selected to eval uate participants’ spirituality. Two groups were created using the response to the question, “How spiritual a person do you consider yourself?” Subjects were asked to rate themselves on a scale of 1 to 7 with 7 meaning “the most spiritual”. Those groups who rated themselves 5, 6, or 7 were considered highly spiritual and coded as 1. Those who rated th eir spirituality as 1,2,3, or 4 were considered le ss spiritual and coded as 0 Indicator of self -health assessment The Rand SF-36 Health Status Questionnair e measures physical functioning, social functioning, role functioning (physical pr oblems) and role functioning (emotional

PAGE 39

29 problems). Additionally, the instrument me asures mental health, fatigue, pain, and general health. One question, “In general would you say your health is”, was used to create two groups for the analysis. If a participant an swered good, very good or excellent, their response was considered as a high self-heal th assessment and coded as 1. If their response was fair or poor, their self-health assessment was considered a low score and coded as 0 Questionnaire data Using the patient’s confidentia l code all questionnaire data was entered using an excel spreadsheet. Miss ing data on questionnair es was entered as a dot. Indicator of diagnosed osteoarthritis A diagnosis of osteoarthritis was recorded by the orthopedic surgeon and is available in e ach individual participan t’s medical record. The diagnosis was verified with the indi vidual’s pre-surgical history and physical assessment. Indicator of ethnicity Ethnicity was obtained from the patient ’s admission record. The admissions department routinely obtains ethnicity info rmation during a patient’s initial interview prior to entering the hospital. Postoperative Data Collection Procedures Indicator of pain scores Individual postoperative pain scores were obtained from the individual’s medical record. Daily pain scores were recorded and averaged for three days postoperatively. Additionally, a daily median pain score was recorded for this same interval. Pain was evaluated using the Visu al Analog Scale (VAS) that evaluates pain intensity numerically using a 0 to 10 measurement (0= no pain, 10= worst pain). The

PAGE 40

30 VAS instrument is used with all age groups and is the approved pain scale for use at Shands Hospital at the University of Florida. Analgesic medication use Medications dispensed during a patient’s hospitalization are records in the Medication Administrati on Record (MARS). The MARS documents each dose of medicine administered by nursing personnel. This medication record contains the medication name, date, time, dosage and initials of hospital personnel administering the medication. Individual Medication Administration Records (MARS) were evaluated for the use of narcotic analge sic medication for every participant. An Opioid equi-analgesic conversion table was us ed and all opiates we re standardized to morphine sulfate equivalents. For example, 1.5 mg IV Hydromorphone = 100 mcg IV/SC Fentanyl = 20 mg P.O. Oxycodone = 10 mg IV Morphine (Pasero, Portenoy & McCaffery, 1999). Total IV Morphine Sulfate equi-analgesic conversion was recorded for each postoperative day for three days. Regional anesthesia use Regional anesthesia techniques such as epidural, Femoral Nerve Sheath Catheters, and Psoais Compartm ent Catheters provide postoperative pain relief by blocking nerve conduction with lo cal anesthetics, thereby blocking the transmission of pain (Pasero, Porteno y, & McCaffery, 1999). The use of a local anesthestic provides a sensory and motor bloc kage. The epidural regional anesthesia technique occasionally re quires the use of an opioid agent in addition to a blocking agent. The use of an opioid agent is recorded on a separate analgesic document in the patient’s medical record. The placement location of regi onal anesthesia is recorded on a separate document located within the patient’s medical record.

PAGE 41

31 Medical record data Medical record data collected included surgical site, anesthesia data, pain scores and analgesic medication used. A form was developed (see appendix) to collect data from the participant’s medical record after discharge. Medical records were requested using a Request fo r Records review and Shands at the UF Research Chart Request forms. An average of 4-20 charts were requested each time; medical records usually required two weeks to be assembled. Several delays were experienced in obtaining medical records that included research medical records personnel vacation days, sick days, and incomp lete delivery of records. One medical record has been lost. Two records are in complete with medication records missing. The Medical Record Department requires th at all data and chart review must be preformed in the records department. Usi ng the coding key, data was recorded on the case coding form. Pain scores were documented as average scores and median pain scores. All opioid medications were converted to Morphine Sulfat e IV equi-analgesics and recorded. Surgical site, anesthesia type, regional anesthesia, general anesthesia were coded using the coding key. Data Analysis Data obtained in the postoperative period were entered on an Excel spreadsheet. Analysis used SPSS statistical software, Vers ion 11 for Windows. Demographic data for spirituality, self-health assessment, age, ge nder, pain scores, a nd analgesic medication use were analyzed to generate descriptive st atistics using mean scores and frequencies The hypotheses were tested with analysis procedures using Pearson’s correlation coefficient, T-Test and ANO VA with significance levels of 0.05. Correlations measure how variables are related and measure their linear association. Frequencies and mean scores were analyzed for all demographic data, age, gender, operative site, physician,

PAGE 42

32 regional anesthesia and analgesic medication use. Individual survey questionnaire items were analyzed using frequency and percen tage of individual participant response. Summary This chapter presented research desi gn, sample inclusion, power analysis, methodology, and data collection procedures for this study. Data analysis methodology for research hypotheses was discussed.

PAGE 43

33 CHAPTER 4 RESULTS A description of the partic ipants and the results of this descriptive study are presented in this chapter. The results are examined in relation to the three hypotheses. This study took place at Shands at the University of Florida. Subject s were recruited as a convenience sample that included only persons that met the inclusion criteria. Informed Consent and questionnaire data were collected in the pre-surgical anesthesia clinic. Demographic data, pain scores and medica tion use were obtained from the subject’s medical record after hospital discharge. A ll data was computed using the SPSS statistical software, version 11 for Windows. Sta tistical significance was set at p < 0.05. Sample Characteristics A total of 126 potential subjects who met th e inclusion criteria were approached to participate in the study. Eleven potential par ticipants declined to participate. Three stated they were “tired of filling out paperw ork”, two did not want to participate in any research and one did not believe in spirituality. Five did not express a reason for refusing participation. None of the potential resear ch participants expressed any fear of an adverse event by participating in this study. A ll subjects who agreed to participate signed an informed consent and completed the two que stionnaires in the pre-operative anesthesia center. At the end of the study one subjec t’s medical record wa s missing from the Medical Records Department and after a deta iled search was considered lost. One subject’s Medication Administration Record was missing from the medical record and

PAGE 44

34 presumed lost. All other part icipants’ medical records were complete at the end of the data collection period. One hundred and fifteen subjects who met th e inclusion criteria were consented. The mean age of the sample was 67.70 (SD = 8.23). Seventyfour (64.3 %) of the participants were female and 41 (35.7%) were males. The majority of the participants were Caucasian (n = 111), followed by Hispanic (n = 2) and African American (n = 1). All participants were diagnosed with severe osteoarthritis and had failed conservative medical management. Right total knee arthroplasty was the joint replacement most frequently performed at 35% (n = 35), followed by left total knee arthroplasty at 27.8% (n = 32) right total hip arthroplasty 18% (n=18), left total hip arthroplasty at 13.9% (n =16), and bilateral total knee arthroplasty at 10.4% (n = 12). Regional Anesthesia Forty-six percent (n = 56) of the participants chose a femoral nerve sheath for postoperative pain control, while 25.2% (n = 29) chose an epidural, 3.5% (n = 4) chose a psoas compartment sheath, and 1.7% chose a continuous spinal. Patient controlled analgesia (PCA) was used by 67% (n = 77) of subjects. The PCA group includes some of the subjects who received a femoral nerve shea th. All other participants selected “as needed” analgesia for post operative pain control. Anesthesia Technique During Surgery General anesthesia was administered to 100 participants (87%) followed by continuous spinal at 4.3% (n = 5), followed by managed anesthesia care at 2.6% (n=3).

PAGE 45

35 Analysis of Data in Relation to the Hypotheses Hypothesis 1 Hypothesis 1 stated that olde r adults with a high degree of spirituality receiving hip or knee arthroplasty for primary osteoarthrit is would report less pain and receive less analgesic medication than those participants with a lower degree of spirituality after controlling for health self-assessment. The Pearson Correlational analysis as show n in Table 3, demonstrated there was no significant correlation between spirituality re sponse, self-health questionnaire response and the following variables: age (r = -0.02, p = 0.84), average pain scores day one (r= 0.01, p = 0.92), average pain scores day two (r = 0.02, p = 0.84), average pain scores day three (r = 0.03, p = 0.78) and analgesic medi cation use (r = -0.04, p = 0.69). A partial correlation coefficient controlling for the self -health assessment score was then analyzed (See Table 4) and there were no significan t correlations between spirituality, and the variables: age (r = -0.05, p = 0.60), pain day one (r = 0.53, p = 0.59), pain day two (r = 0.06, p = 0.53), pain day three (r = 0.06, p = 0.56) and pain medication (r = -0.02, p = 0.81). Hence, Hypothesis 1 was rejected. Hypothesis 2 Hypothesis 2 stated that older adults with a high score on the high self-health assessment tool would report less pain and r eceive less analgesic medication than those participants with a low score on the self-h ealth assessment tool after controlling for spirituality. The Pearson Correlation found there was a significant correlation as shown in Table 5 between the variable for health on th e Short Form-36 Health Survey and age (r = 0.23, p = 0.02), average pain scores day one (r = -0.31, p = 0.00), day two (r= -0.29, p =

PAGE 46

36 0.00) and day three (r = -0.22, p = 0.03). There were similar results for days one, two, and three and median pain scores. However, there was no significant correlation between the variables, analgesic medication use (r = 0.11, p = 0.23) or high spirituality (r = 0.13, p = 0.17) as shown in Table 5. A Pearson Partial correlation for health assessment while controlling for spirituality was analyzed. There was a sta tistically significant correlation for the following variables: age (r = 0.23, p = 0.02), pain scores on day one (r = -0.31, p = 0.00), day two (r = 0.29, p = 0.00), day three (r = -0.22, p = 0.02). Ther e was no significance for less analgesic medication use (r = -0.11, p = 0.26) as show n in Table 6. The results confirmed Hypothesis 2 for pain, but rejected it for analgesic medication use. Hypothesis 3 Hypothesis 3 stated that th ere would be less analgesic medication used in those older adults receiving hip or knee arthropl asty who had a high degree of spirituality involvement and beliefs and a high scor e on the self-health assessment tool. An ANOVA regression was used to determin e if there was an interaction between good to excellent health and a high degree of spirituality. The relationship was not significant (F = 1.04, p = 0.38). Fu rther analysis a T-Test was used to determine if there was a difference in the average analgesic medication use between the high spirituality group and the good to excellent self-a ssessed health group (Ms = 7.63 and 8.49 respectively). Hypothesis 3 was rejected. Additional Findings For the purpose of this research, one ques tion rating degree of spirituality was used from this scale. The SIBS tool was satisfa ctory and demonstrated a Cronbach Coefficient Alpha 0.94 Raw Score. Each participant comp leted the 39-item questionnaire and there

PAGE 47

37 were a many positive responses to specific questi ons on the spirituality and beliefs scale. For example, on the item spiritual health contributes to physical health, 70.4% agreed or strongly agreed. Most part icipants considered themselves spiritual when asked to rate their spirituality on a scale of 1 to 7 (with being the most spiritual). Participants used religious coping such as hope, personal relati onship with a greater pow er than self, and a belief that prayer changes things. A high num ber of participants (77%) wanted others to pray for them during their illness. More th an 70% of the respondents felt that spiritual health contributes to physica l health. Additionally, 95 or 82.6% of the participants always or almost always make an effort to apologize when they do wrong to someone. Overall scores on the SIBS instrument refl ected a positive relationship with a higher power, prayer, a belief in an after life, and continued spiritual growth (see Table 7). Participants expressed difficulty with the SI BS questionnaire and often said, this is too hard to answer or, I have to think a lot. However, no participant asked for clarification of a SIBS question. The Short Form-36 Health Survey For the purposes of this research particip ant response to the question In general would you say your health is: excellent, very good, good, fair, poor was used for analysis. Participants answ ered the 11-item self-assessment tool that queried physical and emotional function. It is of interest th at most were limited a lot for vigorous and moderate activities. Daily ac tivities such as walking, be nding, kneeling and stooping had the highest response for limited a lot. Simp le activities such as dressing and bathing were least limited. The tool seemed easier than the SIBS for participants to complete and there were no missed questions.

PAGE 48

38 Table 1. Frequency and Percent of Variables Variable Frequency Percentage Sex Male 41 35.7 Female 74 64.3 Ethnicity White 111 96.5 African American 1 .9 Hispanic 2 1.8 Operative Site No response 2 1.7 Left Total Hip Arthroplasty 16 13.9 Right Total Hip Arthroplasty 18 15.7 Left Total Knee Arthroplasty 32 27.8 Right Total Knee Arthroplasty 35 30.4 Bilateral Total Knee Arthroplasty 12 10.4 Orthopedic Surgeon Surgeon #1 81 70.4 Surgeon #2 23 20.0 Surgeon #3 11 9.6 Regional Anesthesia No Regional 22 19.1 No Response 1 .9 Epidural 29 25.2 Femoral Nerve Sheath 56 48.7 Psoas Compartment Sheath 4 3.5 Continuous Spinal 2 1.7 Spinal 1 .9 Patient Controlled Analgesia No Response 3 2.6 No PCA 35 30.4 PCA 77 67.0 Anesthesia Type No Response 2 1.7 GETA 100 87.0 Spinal 5 4.3 MAC 3 2.6 Continuous Spinal 5 4.3

PAGE 49

39 Table 2. Summary Measures of Variables Variable N Mean Std. Dev Minimum Maximum Age 115 67.70 8.23 55.00 86.00 Av. Pain Scores day 1 113 3.34 1.99 0 9.13 Av. Pain Scores day 2 111 2.28 2.04 0 7.20 Av Pain Scores day 3 106 2.24 2.15 0 9.20 Median Pain Scores day 1 113 2.97 2.67 0 9.75 Median Pain Scores day 2 111 2.01 2.31 0 9.00 Median Pain Scores day 3 105 2.11 2.38 0 9.00 Health Self115 0.82 0.39 0 1.00 Assessment Spirituality 111 0.69 0.46 0 1.00 Table 3. Pearson Correlation Coefficients -Spirituality and Variables with No Adjustments Variables r value p value n Age -0.02 0.84 111 Pain Day 1 (average) 0.01 0.92 109 Pain Day 2 (average) 0.02 0.84 108 Pain Day 3 (average) 0.03 0.78 103 Pain Day 1 (median) 0.01 0.91 109 Pain Day 2 (median) -0.03 0.75 108 Pain Day 3 (median) 0.10 0.30 102 Analgesic Medication Use Day 1-3 -0.04 0.69 109 Table 4. Pearson Partial Coefficien ts-Controlling for Health Assessment Variables r value p value n Age -0.05 0.60 108 Pain Day 1 (average) 0.05 0.59 106 Pain Day 2 (average) 0.06 0.53 105 Pain Day 3 (average) 0.06 0.56 100 Pain Day 1 (median) 0.05 0.63 106 Pain Day 2 (median) 0.01 0.92 105 Pain Day 3 (median) 0.13 0.18 99 Analgesic Medication Use Day 1-3 -0.02 0.81 106

PAGE 50

40 Table 5. Pearson Correlation Coefficients-H ealth Self-Assessment and Variables with No Adjustments Variables r value p value n Age 0.23 0.02 115 Pain Day 1 (average) -0.31 0.00 113 Pain Day 2 (average) -0.29 0.00 111 Pain Day 3 (average) -0.22 0.03 106 Pain Day 1 (median) -0.26 0.01 113 Pain Day 2 (median) -0.30 0.00 111 Pain Day 3 (median) -0.21 0.04 105 Analgesic Medication Use Day 1-3 -0.11 0.23 113 Spirituality 0.13 0.17 111 Table 6. Pearson Partial Coefficients-Health Self-Assessment and Va riables Controlling for Spirituality Variables r value p value n Age 0.23 0.02 108 Pain Day 1 (average) -0.31 0.00 106 Pain Day 2 (average) -0.29 0.00 105 Pain Day 3 (average) -0.22 0.02 100 Pain Day 1 (median) -0.26 0.01 106 Pain Day 2 (median) -0.30 0.00 105 Pain Day 3 (median) -0.22 0.03 99 Analgesic Medication Use Da y 1-3 -0.11 0.26 106

PAGE 51

41 Table 7. Frequencies and Percentages for SelfReported SIBS Questionnaire (N=115). Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree. Frequency Percentage (1) I set aside time for meditation and/or selfreflection. 51 44.3 (2) I can find meaning in times of hardship. 67 58.3 (3) A person can be fulfilled without pursuing active spiritual life. (disag ree/strongly disagree) 43 37.4 (4) I find serenity by accepting things as they are. 53 45.0 (5) Some experiences can be understood only through one’s spiritual beliefs 64 55.6 (6) I do not believe in an afterlife. (disagree/strongly disagree) 70 60.9 (7) A spiritual force influences the events in my life. 70 60.9 (8) I have a relationship with someone I can turn to for spiritual guidance. 69 60 (9) Prayers do not really change what happens. (disagree/strongly disagree) 79 68.7 (10) Participating in spiritual activities helps me forgive other people. 70 60.9 (11) I find inner peace when I am in harmony with nature. 68 59.2 (12) Everything happens for a greater purpose 70 60.9 (13) I use contemplation to get in touch with my true self. 43 37.4 (14) My spiritual life fulfills me in ways that material possessions do not. (This question is missed by 25 or 21.7% do to its positi on in the questionnaire) 62 53.9 (15) I rarely feel connected to something greater than myself. (disagree/strongly disagree) 62 53.9 (16) In times of despair, I can find little reason to hope. (disagree/strongly disagree) 80 69.6 (17) When I am sick, I would like others to pray for me. 89 77.4

PAGE 52

42 Table 7. Continued Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree. Frequency Percentage (18) I have a personal relationsh ip with a power greater than myself 81 70.4 (19) I have had a spiritual experience that greatly changed my life 57 49.6 (20) When I help others, I exp ect nothing in return. 98 84.2 (21) I don’t take time to appreciate nature. (disagree/strongly disagree) 70 60.9 (22) I depend on a higher power. 70 60.9 (23) I have joy in my life because of my spirituality 74 64.3 (24) My relationship with a higher power helps me love others more completely. 69 60.0 (25) Spiritual writings en rich my life. 61 52.1 (26) I have experienced healing after prayer. 47 40.9 (27) My spiritual understanding continues to grow. 74 64.3 (28) I am right more often than most people. (disagree/strongly disagree) 34 28.0 (29) Many spiritual approaches have little value. 62 53.9 (30) Spiritual health contribute s to physical health. 81 70.4 (31) I regularly interact with others for spiritual purposes. 52 45.2 (32) I focus on what needs to be changed in me, not what needs to be changed in others. 75 65.2 (33) In difficult times, I am still grateful. 91 79.1 (34) I have through a time of gr eat suffering that led to spiritual growth. 51 44.3 The following questions were scored using onl y the response always or almost always (35) When I wrong someone, I make an effort to apologize. 95 82.6 (36) I accept others as they are. 75 65.2 (37) I solve my problems without using spiritual resources. 25 21.7

PAGE 53

43 Table 7. Continued. Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree. Frequency Percentage The following questions were scored using onl y the response always or almost always (38) I examine my actions to see if they reflect my values. 49 42.6 The following question was scored 1-7 with “7” being the most spiritual. Scoring for this question used response 5,6,7. (39) How spiritual a person do you consider yourself? 50 66.9 Table 8. Frequencies and Percentages Ques tions that Indicated Ratings for General Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey questionnaire (N=115). Questions Frequency Percentage (1) In general would you say your health is: response: excellent, very good, good 94 81.73 (2) Compared to one year ago how would you rate your health in general now? Much better 9 7.83 Somewhat better 18 15.65 About the same 61 53.04 Somewhat worse now 23 20.00 Much worse now 4 3.48 (7) How much bodily pain have you had during the past 4 weeks? No response 2 1.74 None 0 0 Very Mild 14 12.17 Moderate 36 31.30 Severe 46 40.00 Very Severe 17 14.78 Additional findings included the increased use of regional analgesic techniques during the last six months of this research. Concurrent research by another investigator enrolled some of these same participants re ceiving total knee arthropl asty in a study using femoral nerve sheath technique to treat postope rative pain. This investigator examined

PAGE 54

44 the pain report outcomes for two of the most frequently used regional analgesia methods of postoperative pain control: epidurals and fe moral nerve sheath catheters. Analysis of these two methods compared the mean pain scores on postoperative days one, two and three. Both techniques had lower mean scores for pain scores on days one, two and three when compared to no regional technique. The epidural provided the lowest mean score day one (M= 2.74) compared to the femoral nerve sheath on day one (M= 3.17). Those participants using PRN analgesia and no regi onal technique had the highest mean pain score on day one (M=4.25). On day two, the femoral nerve sheath provided the lowest mean pain score (M==1.82). On day three all of the regional analgesia had been removed, but the mean pain scores for those persons who received regional analgesia remained similar to days one and two. On a ll three days the PRN analgesia group had the highest mean pain score ( Ms= 4.25, 2.90, and 2.94, respectively). In summary, these findings demonstrated th at participants in this study were in moderate to severe pain and had functiona l limitations preoperatively, but described themselves as in good to excellent health and very spiritual. The use of regional analgesia for postoperative pain control did lowe r pain scores for all days when compared to those who did not receive a regional technique.

PAGE 55

45 CHAPTER 5 DISCUSSION The purpose of this study was to examine the relationships between the degree of spirituality and high scores on a self-hea lth assessment questionnaire with three postoperative outcomes after hip or knee join t arthroplasty. Specifically, this study examined the relationships between a high degree of spirituality, a high score for individual self-health assessment and pain re port and analgesic me dication use for three days after total joint replacem ent surgery. The hypothesized relational statements were based on the need for quantitative data coll ection measuring the relationships between spirituality, health assessment, pain report a nd analgesic medication use. There is no previous empirical research that has examin ed these relationships in the postoperative arthroplasty patient. The study sample consiste d of 115 participants scheduled for hip or knee arthroplasty in a large Southeastern te aching hospital. This chapter will present a discussion of (1) research findings, (2) conclusions, (3) research strengths and weaknesses, and (4) implica tions for nursing practice. Research Findings This section will discuss sample charact eristics, followed by study of findings as they related to the research questions. Sample Characteristics One hundred and fifteen older adults who we re scheduled for hip or knee total joint arthroscopy consented to particip ate in this study. All of the participants were recruited from the pre-surgical anesthesia center of a large teaching hospital. In this convenience

PAGE 56

46 sample, the participant ages ranged from 55 to 86. The average age was 67.70. There were 41 males and 74 females enrolled in this study. This finding is somewhat less than the 2:1 ratio females to males in osteoarthritis prevalence as reported by other researchers (Davis, Ellinger, Newhaus, & Hauck, 1987). Pa rticipants described their generalized body pain as severe or very severe (55%) dur ing the four weeks prior to their scheduled surgery, but self-asse ssed their health as excelle nt, very good or good (81.73%). Anderson, et al. (1993) and Mob ily, et al. (1994) reported sim ilar pain report among older adults. This research found that functional abilities were severe ly limited for vigorous activity such as part icipating in strenuous sports, lifting heavy objects, vacuuming, playing golf walking several blocks, bendi ng, stooping and climbing stairs while more moderate activities such as lifting groceries, bathing and dressing were “limited a little”. Praemer, Furner, & Rice, (1992) and Salmon, et al. (2001) found similar functional limitations in osteoarthritis patients. Ethnicity could not be examined due to the low numbers of African Americans and Hispanics enrolled in this re search. Felson (1988) simila rly found that greater numbers of European whites have osteoarthritis than other ethnicities and this may account for the differences observed in this study. Only one African Ameri can and two Hispanics were enrolled in this research. Socioeconomic status may have been a factor in the low number of other ethnic groups seeking join t replacement. However, socioeconomic status was not considered in this research. Spirituality, Pain Report and Analgesic Medication The first research question examined th e relationship of a high degree of spirituality, postoperative pain scores and analgesic medication use. One research

PAGE 57

47 question was used from the SIBS questionnaire Two groups of participants were created using one research question from the SIBS que stionnaire. Those with high scores for spirituality were considered highly spiritua l. The majority (69.4%) of the respondents were highly spiritual. A part ial correlational analysis was used to identify a relationship between a participants’ high spirituality and the variables, age, pain report for three days and analgesic medication use postoperatively, controlling for self-a ssessed health. There was no relationship for spirituality and th e variables. Therefore, hypothesis 1 was rejected. Participants who have a high degree of spirituality did not tend to have less pain and did not tend to use less analgesic medi cation postoperatively. Although there was a high participant response to spirituality, the possibility of spiritual coping did not tend to influence pain or pain medicine use after joint replacement surgery. Health Self-Assessment, Pain Report and Analgesic Medication Use It was hypothesized that participants who consider themselves healthy will report less pain and use less analgesic medication po stoperatively. The health variable “In general would you say your h ealth is: excellent, very good, good” was used to identify those participants with a high score on hea lth assessment. Of the participants, 81.7% rated their health in this positive way. Correlation analysis found that persons who considered themselves healthy tended to have less pain on each day postoperatively but they did not tend to use less pain medicat ion. Therefore, there was no association between high health scores and less pain medi cation use. Further analysis using a partial correlation controlling for th e spirituality variable, found similar results; a healthy assessment was related to less pain for th e three days postoperatively and had no relationship with the amount of pain medication.

PAGE 58

48 In summary, participants who rated se lf-health as good, very good or excellent tended to experience less pain during the first three days pos toperatively. However, these same participants did not tend to use less pain medication. Research question 2 was accepted for less pain, but rejected for less pain medication use. Impact of Health Assessment and Spiritual ity on Pain Reports a nd Analgesic Medication Use Lastly, it was hypothesized that participants who considered themselves to be very spiritual and healthy would use less anal gesic medication duri ng their postoperative recovery. A regression analysis was used to determine possible interactions between health assessment and spirituality and analgesic medication use. There was no relationship between the variab les and pain medication. A further T-Test was used to determine if there was a difference between th e high spirituality and the high self health assessment groups in analgesic medication use. The T-Test found no mean difference between the two groups. Therefore, Hypothesis 3 was not accepted. Those participants w ho self-rated their health as good, very good or excellent and considered their spirituality as high did not tend to experience less pain or use less pa in medication than did the other research participants. Conclusions Although participants reported moderate to severe bodily pain and a decrease in functional activity on a health questionnaire, they considered themselves to be healthy. There was a relationship between self-health and pain for the first three days after surgery. It demonstrated that how a person vi ews their health contributes to the amount of pain they experience after joint replacemen t. Additionally, less pain experienced did

PAGE 59

49 not mean less pain medication used. There has been no previous research evaluating relationships between how hea lthy an individual feels and the amount of pain medication used after surgery. Previous research that has evaluated h ealth status has been with individuals who were in “poor health” w ith long-term disab ility after surgery. Most participants considered themselves to be highly spiritual and used spiritual coping methods such as hoping, praying and dependence on a higher power. There is no previous research that has examined the sp irituality and postoperative pain or pain medication use after joint replacement surger y. Previous research that evaluated spirituality, health assessment and functiona l recovery used a very different patient population. The only similarity was a high degr ee of spirituality among the older adult rehabilitation patients (Fitchett, et al. 1999; Kim, et al. 2000; Pressman, et al. 1990). In my research, most reported that they used spiritual coping me thods and behaviors such as participation in spiritual activities, spiritual writings and prayer. They also believe their spiritual health contributes to their physical health. The majority of the participants in this research used these spiritual coping me thods. However, there was no evidence that high self-evaluation for spirituality influenced pain or pain medication use after total joint replacement surgery. Strengths and Limitations Although this research had strengths, it was limited in its methodology. Primarily it was a convenience sample of pre-operative total joint arthroscopy patients. This research was impaired by the use of regi onal anesthesia by the majority of the participants. These patients received more re gional anesthesia techni ques for pain control postoperatively than most othe r surgical patients. Regiona l analgesia is an effective technique in the treatment of post-operat ive arthroplasty pain. Pain report and

PAGE 60

50 medication use for this group of patients we re affected by the use of the regional anesthesia techniques. It was not possible to control for the increase in regional analgesia techniques during th is investigation. There was an uneven distribution of males a nd females. This was to be expected, but did not approach the 2:1 ra tio for osteoarthritis found in previous research. There was no ethnic diversity found in this research a nd this finding does not represent the ethnic distribution in the geographic region. Implications for Nursing Practice and Future Study There is evidence from this study that these patients requ iring total joint replacement for osteoarthritis have a high degr ee of spirituality and perceive their health as good to excellent. They use spiritual copi ng and behaviors such as prayer, spiritual activities, and belief that spiritual health influe nces physical health. Second, they feel their hea lth is good to excellent re gardless of their functional limitations or pain. This self-assessment of good h ealth contributed to le ss pain after total joint surgery, but did not lessen the need for pain medication. It is important that the clinician reco gnize that the postoperative patient is multidimensional in their self-h ealth and their spirituality. This quantitative study did not support the hypothesis that spirit uality decreases pain or pa in medication use. This research did find a relationship between self -assessed good health and decreased pain, but did not find a relationship in less pain medicine use. This research contributes to the body of literature evaluating spirituality and health in the older adult. Future research should include postoperati ve function and pain using longitudinal data collection. Assessing jo int arthroplasty subjects pre-operatively, one month postoperatively and at the end of the one-year recovery peri od would provide long-term

PAGE 61

51 data on the relationships between spiritualit y, self-health assessment, pain and physical function. Correlating functional longitudinal da ta with spirituality and health assessment would provide more pertinent information without interference from postoperative regional analgesia. The implications of this study for nursing pr actice are that the findings of this study support the use of spirituality and spiritual beha viors by the majority of the participants. Good to excellent self-health assessment did ch ange the amount of pain these participants reported after surgery. Nurses should be more at ease in assessing a patient’s spirituality and self-health. Nurses do have to recognize that how a patient eval uates self-health may be important in reducing postope rative joint arthroplasty pain. In summary, evaluating the participants’ spirituality and self-health assessment found interesting relationships between postope rative pain and analgesic medication use. Second, these research findings have implicati ons for further future nursing research.

PAGE 62

APPENDIX A LETTER OF AGREEMENT

PAGE 63

53

PAGE 64

APPENDIX B INFORMED CONSENT 08-19-03 TO 07-15-04

PAGE 65

55

PAGE 66

56

PAGE 67

57

PAGE 68

58

PAGE 69

59

PAGE 70

60

PAGE 71

61

PAGE 72

APPENDIX C INFORMED CONSENT 01-29-04 TO 07-15-04

PAGE 73

63

PAGE 74

64

PAGE 75

65

PAGE 76

66

PAGE 77

67

PAGE 78

68

PAGE 79

69

PAGE 80

APPENDIX D INFORMED CONSENT 07-16-04 TO 07-15-05

PAGE 81

71

PAGE 82

72

PAGE 83

73

PAGE 84

74

PAGE 85

75

PAGE 86

76

PAGE 87

77

PAGE 88

78 APPENDIX E THE SHORT FORM-36 HEALTH SURVEY —SPIRITUAL INVOLVEMENT AND BELIEFS SCALE

PAGE 89

79

PAGE 90

80

PAGE 91

81

PAGE 92

82

PAGE 93

83

PAGE 94

84

PAGE 95

85

PAGE 96

86

PAGE 97

87 LIST OF REFERENCES Aarons, H, Hall, G., Hughes, S., & Salmon, P. (1996). Short-term recovery from hip and knee arthroplasty. The Journal of Bone and Joint Surgery, 8, 555-558. Affleck, G., Tennen, H., Keefe, F.J., Lefe bvre, J.C., Kashukar-Zuck, S., Wright, K., Starr, K., & Caldwell, D.S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: independent e ffects of disease and gender on daily pain, mood, and coping. Pain, 83, 601-609. American Geriatrics Society. (1998). The management of chr onic pain in older persons. Journal of the American Geriatrics Society, 46, 174-192. Anderson, H.I., Ejlertsson, G., Leden, I., & Rosenberg, C. (1993). Chronic pain in a geographically defined general population: Studies of difference in age, gender, social class, and pain localization. The Clinical Journal of Pain, 9, 174-192. Bates, M.S., Edwards, W.T., & Anderson, K.O. (1993). Ethnocultural influences on variation in chronic pain perception. Pain, 52, 101-112. Brander, V.A., Mullarkey, C.F., & Stulberg, S.D. (2001). Rehabilita tion after total joint replacement for osteoarthritis : An evidence based approach. Physicial Medicine and Rehabilitation, 15, 175-197. Burkhardt, M.A., (1989). Spirituality: An analysis of the concept. Holistic Nursing Practice, 3, 69-77. Clark, K.M., Friedman, H.S., & Martin, L.R. (1999). A longitudinal study of religiosity and mortality risk. Journal of Health Psychology, 4, 381-391. Davis, M.A., Ettinger, W.H., Newhaus, J. M., & Hauck, W.W. (1987). Sex difference in osteoarthritis of the kne e: the role of obesity. Journal of Epidemiology, 127, 10191029. Diehl, M., Coyle, N., & Labouvie-Vief, G. (1996) Age and sex difference in strategies of coping and defense across the life span. Psychology and Aging, 11, 127-139. Ekblom, A., & Rydh-Rinder, M. (1998). Pa in mechanisms: anatomy and physiology. In N. Rawal, (Eds). Management of acute and chronic pain (pp. 1-22). London: BMJ. Ellison, C.G., & Levin, J.S. (1998). The religion -health connection: evidence, theory, and future directions. Health Education & Behavior, 25, 700-720.

PAGE 98

88 Erdfelder, E., Faul, F., & Buchner, A. (1996). GPOWER: A general power analysis program. Behavior Research Methods, Instruments, and Computers, 28:1, 1-11. Escalante, A., Espinosa-Morales,R., Del Ri ncon, I., Arroyo, R.A., & Older, S.A.(2000). Recipients of hip replacement for arth ritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis & Rheumatism, 43, 390-399. Felson, D.T., (1988). Epidemiology of hip and knee osteoarthritis. Epidemiologic Reviews, 10, 1-24. Ferrell, B.A., (2000). Pain management. Clinics in Geriatric Medicine, 16, 853-871. Fitchett, G., Rybarczyk, B.D., & DeMarco, G. A.(1999). The role of religion in medical rehabilitation outcomes: a longitudinal study. Rehabilitation Psychology, 44 333351. Gagliese, L., & Melzack, R.C. (1997). The assessment of pain in the elderly. In D.I. Mostofsky & J. Lomaranz (Eds.), Handbook of pain and aging (pp. 69-96). New York: Plenum. Gibson, S.J., & Helme, R.D. (1995). Age diffe rences in pain perception and report: a review of physiologic, psychological, laboratory and clinical studies. Pain Reviews, 2, 111-137. Hatch, R.L., Burg, M.A., Naberhaus, D.S., & Hellmich, L.K. (1998). The spiritual involvement and beliefs scale: Development and testing of a new instrument. Journal of Family Practice, 46, 476-486. Healy, W. I., Iorio, R., & Lemos, N.J. (2001). Athletic activity afte r joint replacement. The American Journal of Sports Medicine, 29, 377-388. Hodges, S.D., Humphreys, S.C., & Eck, J.C. (2002). Effect of spir ituality on successful recovery from spinal surgery. Southern Medical Journal, 95,12, 1381-4. Husaini, B.A., Blasi, A.J., & Miller, O. (1999) Does public and private religiosity have a moderating effect on depression ? A bi-racial study of elde rs in the American South. International Journal of Ag ing and Human Development, 48, 63-72. Katz, J.N., Wright, E.A., Guadagnoli, E., Li ang, M.H., Karlson, E.W., & Cleary, P.D. (1994). Differences between men and wome n undergoing major orthopedic surgery for degenerative arthritis. Arthritis & Rheumatism, 37, 687-694. Keefe, F.J., Lefebvre, J.C., Egert, J.R., Affleck, G., Sullivan, M.J., & Caldwell, D.S. (2000). The relationship of gender to pai n, pain behavior, and disability in osteoarthritis patients: Th e role of catastrophizing. Pain, 87, 325-334.

PAGE 99

89 Kim, J., Heinemann, A.W., Bode, R.K., S ilwa, J., & King, R.B. (2000). Spirituality, quality of life, and functional rec overy after medical rehabilitation. Rehabilitation Psychology, 45, 365-385. Koenig, H.G., George, L.K., Blazer, D.G., Pr itchett, J.T. & Meador, K.G. (1993). The relationship between religion and anxiety in a sample of community-dwelling older adults. Journal of Geriatric Psychiatry, 26, 65-93. Koenig, H.G., George, L.K., Hays, J.C., Larson, D.B., Cohen, H.J., & Blazer, D.G. (1998). The relationship between religious activities and blood pressure in older adults. International Journal of Psychiatry in Medicine, 28, 189-213. Koenig, H.G., George, L.K., Meador, K.G., Blazer, D.G., & Dyck, P.B. (1994). Religious affiliation and psychiatric disorder among Protestant baby boomers. Hospital and Community Psychiatry, 45, 586-596. Koenig, H.G., & Larson, D.B. (1998). Use of hospital services, relig ious attendance, and religious affiliation. Southern Medical Journal, 18, 925-932. Koenig, H.G., McCullough, M.E., & Larson, D.B. (2001). Handbook of religion and health, New York: Oxford University Press. Lawrence, R.C., Helmick, C.G., Arnett, F.C., Deyo, R.A., Felson, D.T., Giannini, E.H., et al. (1998). Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis & Rheumatism,41,5, 778-799. Lazarus, R.S., DeLongis, A., Folkman, S., & Gruen, R. (1985). Stress and adaptational outcomes. American Psychologist, 40, 770-779. Levin, J.S., & Chatters, L.M. (1998). Religi on, health, and psychol ogical well-being in older adults. Journal of Aging and Health, 10, 504-531. Levin, J.S., & Vanderpool, H.Y. (1990). Is religion therapeutical ly significant for hypertension? Social Science Medicine, 29, 69-78. Matthews, D.A., McCullugh, M.E., Larson, D. B., Koenig, H.G., Swyers, A., & Milano, M.G. (1998). Religious commit ment and health status. Archives of Family Medicine, 7, 118-124. McFadden, S.H., & Gerl, R.R. (1990). Appro aches to understanding spirituality in the second half of life. Generations 23, 35-38 McFadden, S. H., & Levin, J.S. (1996). Relig ion, emotions and health. In C. Magi & S.H. McFadden (Eds.), Handbook of emotion, adult development, and aging (pp. 349-365). San Diego, CA: Academic Press.

PAGE 100

90 McGuigan, F.X., Hozack, W.J., Moriarty, I, Eng, K., & Rothman, R.H. (1995). Predicting quality of life outcomes following total joint arthroplasty. The Journal of Arthroplasty, 10, 742-7. Meador, K.G., Koenig, H.G., Hughes, D.C., Blazer, D.G., Turnbull, J., & George, L.K. (1992). Religious affiliation and major depression. Hospital and Community Psychiatry, 43, 1204-1208. Mobily, P.A., Herr, K.A., Clark, M.K., & Wallace, R.B. (1994). An epidemiologic analysis of pain in the elderly. Journal of Aging and Health, 6, 139-154. Norman-Taylor, F.H., Palmer, C.R., & Villar R.N. (1996). Quality of life improvement compared after hip and knee replacement. The Journal of Bone and Joint Surgery, 78-B, 74-7. Paragment, K.I., Ensing, D.S., Falgout, K ., Olsen, H., Reilly, B., Van Haitsma, K., & Warren, R. (1990). God help me (1): Religi ous coping efforts as predictors of the outcomes to significant negative life events. American Journal of Community Psychiatry, 18, 793-824. Pargament, K.I., Smith, B.W., Koenig, H.G., & Perez, I. (1998). Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion, 37, 710-724. Pasero, C., Portenoy, R.K., & McCaffery, M. (1999). Opoid analgesics. In M. McCaffery & C. Pasero (Eds.), Pain: Clinical manual (pp. 161-299) St. Louis, MO: Mosby Paulson, P.E., Minoshima, S., Morrow, T.J., & Casey, K.I. (1998). Gender differences in pain perception and patterns of cereb ral activation during noxious heat stimulationin humans. Pain, 76, 223-239. Pellino, T.A., Preston, A.S., Bell, N., Newton, M.J. & Hansen, K. (2002). Complications of orthropaedic disorders and orthopaed ic surgery. In S.W. Salmond & T.A. Pellino (Eds.), Orthopaedic nursing (3rd ed. pp. 234-270). Philadelphia: W.B. Saunders. Porter, F.L., Malhotra, K.M., Wolf, C.M., Mo rris, J.C., Miller, J.P., & Smith, M.C. (1996). Dementia and response to pain in the elderly. Pain, 68, 413-421. Praemer, A., Furner, S., & Rice, D.P. (1992). Musculoskeleta l conditions in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons. Praemer, A., Furner, S., & Rice, D. P. (1999). Musculoskeletal conditions in the United States Rosemont, IL: American Academy of Orthopaedic Surgeons. Pressman, P.A., Lyons, J.S., Larson, D.B., & Strain, J.J. (1990). Religious belief, depression, and ambulation status in elderly women with broken hips, American Journal of Psychiatry, 6 758-760.

PAGE 101

91 Principe, W., (1983). Toward defining spirituality. Studies in Religion, 12, 127-141. Rand Corporation, & Ware, J.E. (1990). The short form-36 health survey. In I. McDowell & C. Newell (Eds.) Measuring health: A guide to rating scales and questionnaires (2nd ed, pp.446-456). New York: Oxford Press. Ritter, M.A., Albohm, M.J. Keating, E.M ., Faris, P.M., & Meading, J.B. (1995). Comparative outcomes of total joint arthroplasty. The Journal of Arthroplasty, 10, 737-741. Ritter, M.A. Eizember, L., Keating, E.M., & Fa ris, P.M. (1995). The influence of age and gender on the outcome of total knee arthroplasty. Today’s O.R. Nurse, 17, 12-15. Rowe, J.W., & Kahn, R. L. (1998). The structur e of successful aging. In J.W. Rowe & R. L. Kahn (Eds.). Successful aging: The MacArthur Foundation Study (pp.36-52). New York: Pantheon. Roy, C., & Andrews, H.A. (1999). The Roy adaptation model. Stamford, CT: Appleton & Lange. Schlesinger, N., (2001). Osteoarthritis: pa thology, epidemiology, and risk factors. Physical Medicine and Rehabilitation, 15, 1-9. Shields, R.K., Enloe, L.J., & Leo, K.C. (1999). Health related quality of life in patients with total hip or knee replacement. Arch. Physical Medici ne & Rehabilitation, 80, 572-579. Shulik, R.N., (1988). Faith development in older adults. Educational Gerontology, 14, 201-301. Zatzick, D.F., & Dimsdale, J.E. (1990). Cultural variations in response to painful stimuli. Psychosomatic Medicine, 52, 544-557. Zhan, L., (2000). Cognitive adaptation and se lf-consistency in hearing-impaired older persons: Testing Roy’s adaptation model. Nursing Science Quarterly, 13, 158-165.

PAGE 102

92 BIOGRAPHICAL SKETCH Patricia Anne McNally was born in Wate rloo, New York. She graduated from St. Mary’s Hospital, School of Nursing, Rocheste r, New York. Pat attended the University of Florida and received a Bach elor of Science in Nursing in 1981. A Master of Science in Nursing degree with a specialization in adult and women’s health was received from the University of Florida in 1999. Ms. McNa lly’s current nursing specialty area is the pre-surgical center at the University of Florid a. She is a member of Sigma Theta Tau, the International Honor Society for Nursing. Ms. McNally’s nursing career has included emergency department staff nursing, charge nursing, nursing and business admini stration, and currently advanced nurse practitioner. She resides in Gain esville, Florida. Pat is the mother of three adult children and the “Mamasita” to th ree young grandchildren.


Permanent Link: http://ufdc.ufl.edu/UFE0008386/00001

Material Information

Title: The Relationship of Spirituality and Self-Health Assessment in Predicting Postoperative Pain and Analgesic Use
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0008386:00001

Permanent Link: http://ufdc.ufl.edu/UFE0008386/00001

Material Information

Title: The Relationship of Spirituality and Self-Health Assessment in Predicting Postoperative Pain and Analgesic Use
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0008386:00001


This item has the following downloads:


Full Text












THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN
PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE















By

PATRICIA A. MCNALLY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2004

































Copyright 2004

by

Patricia A. McNally

































To my family.















ACKNOWLEDGMENTS

There is no adequate way to thank my children, Jimmy, Meghan and Kerry. for all

of their support and love during my doctoral studies. I could not have completed this

work without their belief in me, the frequent phone calls, visits, and words of

encouragement. Lastly, I hope my grandchildren may you love and appreciate the

educational process with the wonder that I have experienced throughout my lifetime.

I would also like to thank my supervisory committee for their knowledge, guidance

and encouragement in supporting me. Especially, I would like to thank Sharleen

Simpson, my chair. Her constant patience and guidance and belief that "you can do this"

gave me such support throughout this doctoral process. Additionally, thanks go to

Hossein Yarandi for his valuable assistance in analyzing data, and to Dr. Donald Caton, a

teacher and friend, who has been a leader in relieving pain. Through his example, he

brings out the best in all of us. Finally, thanks go to Dr. Monika Ardelt who has pursued

research that includes the study of spirituality and geriatrics. I will always be indebted to

all of them for their direction.

I am grateful to Dr. Peter Gearen, Chairman, Orthopaedic Department, and Dr. Nik

Gravenstein, Chairman, Anesthesia Department, for their support in designing and

implementing this research. Additionally, I want to thank the Pre-Surgical Center

administration for supporting the importance of this research and providing access to

patients.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iv

L IST O F TA B LE S ........ .................... ...... .................... ........ .............. viii

ABSTRACT .............. .......................................... ix

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

Background and Significance ......................................................... .............. 3
Chronic Pain in the Older Adult ................................ ....... ...............3
Osteoarthritis and Chronic Joint Pain in the Older Adult...................................4
Total Joint A rthroplasty in the Older A dult ........................................ ...............5
Spirituality in Older A dults ............................................................................5
Sum m ary ...................................... ................................... .................... 7
Specific A im s........................................................ 7
T erm inology ................................................................. 8

2 REV IEW OF TH E LITERA TU RE ...........................................................................10

Presence of Musculoskeletal Chronic Pain and Arthritis Among Older Adults ........10
The Relationship of Background Contextual Stimuli and Pain...............................11
A ge, Pain, and O steoarthritis..................................... ................... ...... ......... .. 11
Gender, Pain and Osteoarthritis..................... ..... ........................... 12
Age, Gender, and O steoarthritis ...................................................................... 12
R ace, Pain and O steoarthritis ........................................ ......................... 13
Total Joint A rthroplasty ......................................................................... .. 14
P re v a le n c e .................................................................................. 14
Gender and Arthroplasty .................................. .....................................15
R ace an d A rthroplasty ........................................... ........................................ 16
S p iritu al C o p in g ............ ....... ........................................................ .. .... .. .. .. .. 16
Spiritual C oping and H health ........................................................... .................. 18
Relationships between Spiritual Beliefs, Gender and Race .............................21
Roy Adaptation Model-Based Research .................................. ...............22
Roy Adaptation Model Gerontologic Research ...............................................23
S u m m a ry ......................................................................................................2 4



v









3 M E T H O D S ....................................................... 25

R e se arch D e sig n ................................................................................................... 2 5
Controls ................................ ..... ................25
Pow er Analysis and Sam ple Size ............................................. ............... 26
Procedures ............................ ................ 26
Protection of Human Subjects .......................... .................. ........ 27
Method .......................... ..............................27
Measures .......... ... ..... ......... .. ...............28
Preoperative Questionnaire M measures ...................................... ............... 28
Indicator of spirituality .......................................... .............................. ... 28
Indicator of self-health assessm ent ................................... ............... ..28
Indicator of ethnicity .............................................. ........ .......... .. ..29
Postoperative Data Collection Procedures .................................. ............... 29
D ata A n aly sis ............................................................. ..................... .. 1
S u m m a ry ................................ ....................................................3 2

4 R E S U L T S .............................................................................3 3

Sam ple Characteristics ........................................ ............................... 33
R regional A nesthesia ................... .............. ............ .. ...... ... ........ .... 34
Anesthesia Technique During Surgery ............. .................... .................34
Analysis of Data in Relation to the Hypotheses............................. ..............35
H y p oth esis 1 ........................................................................3 5
H hypothesis 2 .......................................................................35
H hypothesis 3 .......................................................................36
A additional Findings .......................................... ... .... ........ ......... 36
The Short Form -36 H health Survey ........................................ ......... ............... 37

5 D ISCU SSIO N ............. ........... .... ......... .. ........... ............ ... 45

R research F in ding s........... .................................................................... ........ .. ...... .. 4 5
Sample Characteristics ................................ ........ .. ...................45
Impact of Health Assessment and Spirituality on Pain Reports and Analgesic
M education U se ...................................... ........................... .... ........ ......48
C onclu sion s .................................................... ........................ 4 8
Strengths and Limitations....................................... ................... 49
Implications for Nursing Practice and Future Study .......................................50

APPENDIX

A LETTER OF AGREEMENT................................................ ............... 53

B INFORMED CONSENT 08-19-03 TO 07-15-04 ................................................55

C INFORMED CONSENT 01-29-04 TO 07-15-04 ............................................... 63









D INFORMED CONSENT 07-16-04 TO 07-15-05 ............... ................... ............71

E THE SHORT FORM-36 HEALTH SURVEY-SPIRITUAL INVOLVEMENT
A N D B E L IE F S SC A L E ..................................................................... ..................78

LIST OF REFEREN CES ........ ......................................................... ............... 87

B IO G R A PH IC A L SK E TCH ..................................................................... ..................92
















LIST OF TABLES


Table page

1 Frequency and Percent of Variables...................................................................... 38

2 Summary Measures of Variables ................................................... ................39

3 Pearson Correlation Coefficients-Spirituality and Variables with No
A dju stm en ts ...................................... ............................... ................ 3 9

4 Pearson Partial Coefficients-Controlling for Health Assessment ..........................39

5 Pearson Correlation Coefficients-Health Self-Assessment and Variables with No
A dju stm ents ...................................... ............................... ................. 4 0

6 Pearson Partial Coefficients-Health Self-Assessment and Variables Controlling
for Spiritu ality ........................................................................40

7 Frequencies and Percentages for Self- Reported SIBS Questionnaire (N=115). ....41

8 Frequencies and Percentages Questions that Indicated Ratings for General
Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey
questionnaire (N =1 15) .................. ..................................... .. ........ .. 43















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN
PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE

By

Patricia A. McNally

December 2004

Chair: Sharleen Simpson
Major Department: Nursing

The purpose of this descriptive study was to investigate relationships between

spirituality and self-heath with three postoperative outcomes after total hip or knee

arthroplasty in the older adult.

A total of 115 subjects between the ages of 55 and 86 years of age (M = 67.8) who

met the inclusion criteria were enrolled in this study. Forty-one were male and seventy-

four were female. One question from the Spiritual Involvement and Beliefs Scale and

one question from the Short Form-36 Health Survey were used to measure spirituality

and self-health assessment. Operative site, average daily pain scores, median daily pain

scores and analgesic medication use data were obtained from the patient's medical record

for three days postoperatively.

Bivariate analysis found that those participants with a high degree of spirituality

did not report less pain on days one (r = 0.01, p = 0.92), day two (r = 0.02, p = 0.84) or

day three (r = 0.03, p = 0.78). They also did not use less analgesic medication during the









three postoperative days (r = -0.04, p = 0.69). However, those participants who self-

assessed their health as good to excellent did have less pain on day one (r = 0.31, p =

0.00), day two (r = -0.29, p= 0.00) and day three (r = -0.22, p = 0.02). There was no

reduction in analgesic medication use (r = -0.11, p = 0.25). An ANOVA regression

found there was no relationship for a high degree of spirituality, a high self-health

assessment and the use of less pain medication (F = 1.04, p = 0.38).

The study supported the hypothesis that older adults who rate their self-health as

good, very good or excellent experienced less postoperative pain but this study did not

support less pain medication use. Second, this research did not support the hypothesis

that a participant's spirituality influences pain or analgesic medication use after

arthroplasty surgery. Third, a high degree of spirituality and good health together did not

make a difference in the amount of analgesic medication used for pain control.

The majority (81.7%) of the participants felt their health was good, very good or

excellent. Second, most (67%) indicated they were highly spiritual and 70% felt that

spiritual health contributes to physical health. Finally, the majority of the respondents

believe in spiritual coping behaviors such as prayer, belief in an afterlife and a personal

relationship with a greater power.

This research found that an individual who rates their self-health as good, very

good or excellent has less pain after arthroplasty surgery, but this self-health assessment

does not influence the use of pain medication. Although participants considered

themselves "highly spiritual", their spirituality did not influence postoperative pain or

pain medication use.














CHAPTER 1
INTRODUCTION

The increased number of aging persons has stimulated researchers to define the

concept of aging as viewed by older adults in our society. Rowe & Kahn, (1998) define

successful aging as the avoidance of disease and disability, social involvement and high

level of cognitive and physical function. Success, according to their definition, includes

few physical limitations, health, and the absence of chronic pain. Most adults over 55 yrs

of age do not report problems with daily activities such as: walking, bending and

stooping without assistance. In this age group, however, chronic pain can limit the level

of functional activity. A chief cause of chronic pain and disability among adults over 55

is osteoarthritis

The experience of chronic pain in the elderly is both a physiologic and emotional

experience. Although rooted in sensory stimuli, pain also has an important overlay from

an individual's culture and experience (Porter, et al. 1996). Among all age groups pain

can be defined as an experience with both a sensory and emotional component, but for

the elderly adult, pain may signify a chronic condition that is not always managed

effectively with drug treatment. The most frequent cause of chronic pain and total

disability reported by the older adult is arthritis (Affleck, et al. 1999; Felson, 1988;

Mobily, Herr, Clark, & Wallace, 1994; Praemer, Fumer & Rice, 1999; Schlesinger,

2001).

The American Geriatrics Society suggests using both pharmocologic and non-

pharmocologic methods to achieve a greater degree of pain relief (American Geriatrics









Society, 1998; Gagliese & Melzak, 1997). Non-pharmocologic methods of pain control

include massage, acupuncture, and behavioral therapy. Keefe, et al. (2000) in a study of

rheumatoid arthritis and joint replacement, found that effective coping strategies included

praying, hoping and calming self-statements.

Research on the relationship of spirituality and health has gained increasing interest

in the academic and popular press over the past 15 years. Most early research used

retrospective data analysis to study the effects of religious affiliation, and hypertension,

depression, mortality, and anxiety (Clark, Friedman, & Martin, 1999; Husaini, Blasi, &

Miller, 1999; Koenig, George, Blazer, Pritchett, & Meador, 1993; Koenig, George,

Meador, Blazer, & Dyck, 1994). They observed a positive correlation between church

attendance and various correlates, such as hypertension, depression, anxiety, hospital

length of stay, and mortality (Koenig, et al. 1993; Koenig & Larson, 1998; Meador, et

al. 1992).

Levin and Chatters (1998) suggest future quantitative studies to evaluate

relationships between spirituality and health. Although older people may rely more on

defensive coping strategies, the possibility that spiritual coping mechanisms may have a

therapeutic effect has not been explored. Such spiritual coping mechanisms might

include prayer, religious service attendance, and seeking a spiritual connection (Ellison &

Levin, 1998; Koenig & Larson, 1998; Pargament, Smith, Koenig, & Perez, 1998). These

studies suggest that older adults who use spiritual coping methods during stressful

medical conditions have a more positive health outcome.

I wished to explore the effect of spiritual belief, spiritual behavior and health self-

assessment on the response to postoperative pain. Towards this end I examined the









relationship between specific assessments of spiritual behavior, health self-assessment, to

reports of pain report and the use of analgesic medications among a group of older adults

recovering from hip replacements surgery.

Background and Significance

Chronic Pain in the Older Adult

Pain is defined as a noxious physical and emotional experience. Although similar

for all age groups, elderly adults appear to have a higher incidence of chronic pain. The

only measure of the presence and intensity of pain is the report of the person

experiencing the pain (Ferrell, 2000). Nociceptor pain, including chronic pain, begins

with the activation of special receptors and afferent fibers by peripheral stimuli usually

associated with processes involving tissue damage and inflammation (Ekblom & Rydh-

Rinder, 1998). Such pain may include musculoskeletal pain, ischemic pain, visceral pain,

and myofascial pain. There is little empirical evidence that biological or physiological

measurements correlates to the degree of pain expressed by the elderly individual

(Gagliese & Melzack, 1997). In other words, to a large extent the 'experience' of pain is

subjective.

Among the elderly, research indicates that more than 90% of the elderly experience

pain in the musculoskeletal system (Anderson, Ejlertsson, Lenden & Rosenberg, 1993).

Chronic arthritic joint pain begins in the upper extremities such as shoulders and then

progresses to the lower extremity as an individual ages (Anderson, et al. 1993; Mobily ,

et al. 1994). This site of the pain can greatly affect severity of chronic pain as well as the

degree of functional impairment.









Osteoarthritis and Chronic Joint Pain in the Older Adult

Osteoarthritis is the most frequent cause of end stage joint deterioration and chronic

pain in the elder adult. In the early stage, there is only a pathologic loss of cartilage. As

the disease advances joint cartilage and underlying bone are affected, with a total loss of

cartilage and joint space. Joint cartilage serves two functions: 1) smooth frictionless

surface movement of articulating bones, and 2) transmission of the weight bearing load.

Additionally, extensive tissue inflammatory changes surround the affected joint and

contribute to the limitation of joint range of motion and severe chronic pain (Schlesinger,

2001). Visible osteophytes or lateral outgrowths of bone in the joint margins add to an

increased sclerosis of underlying bone that contributes to an additional increase in

functional impairment (Felson, 1988; Schlesinger, 2001). This loss of the articular

cartilage can be demonstrated radiographically as a joint space narrowing and

occasionally, osteophyte formation. The most frequently affected joint locations are

knees, hips, fingers, and spine (Praemer, et al. 1999).

Measurement of the impact of arthritis includes two parameters: disability or

functional impairment and economic health care system impact. The adult person 65

years of age with arthritis may have more limitations of activity than those afflicted with

other chronic disease states such as cardiac disease, diabetes, and cancer. It has been

estimated that 50% of those persons 65 years of age and older experience activity

limitation from the chronic pain of osteoarthritis (Mobily, et al. 1994). The failure of

conservative medical management, such as medications and physical therapy, in the

treatment of end stage joint osteoarthritis, has increased the demand for surgical total

joint replacement.









Total Joint Arthroplasty in the Older Adult

The early 21st century has been declared the "Bone and Joint Decade" by 35 nations

and 44 states. Currently, more than 425,000 total joint replacements are performed each

year in the United States, and this number is expected to reach 702,000 by the year 2030

as the baby boomer generation ages (Praemer, et al. 1999). The increase in the number of

aging Americans, the increase in the prevalence of arthritis for this age group, and the

desire to remain active have added to the increase in demand for total joint replacement

surgery (Healy, Iorio, & Lemos, 2001). Joint replacement surgery has been documented

to improve pain, functional ability, social function, and quality of life for the recipient

(Aarons, Hall, Hughes, & Salmon, 1996; McGuigan, Hozack, Moriarty, Eng, &

Rothman, 1995; Norman-Taylor, Palmer, & Villar, 1996; Ritter, Albohm, Keating, Faris,

& Meading, 1995).

These findings demonstrate that osteoarthritis among older adults is a major cause

of chronic pain and functional impairment. Total joint replacement offers the older adult

pain relief and improved functional ability, particularly when there is failure with

conservative therapies.

Spirituality in Older Adults

Behavioral management of pain includes the strategy of active coping. Spiritual

coping behaviors that include praying and church attendance have been recognized as

active coping behavioral strategies used often by older adults (Koenig, et al. 1998).

Burkhardt, (1989) defines the "spirituality" as the individual's belief in God or a higher

power that is concerned with his or her striving to achieve a sense of harmony with self

and others. Spirituality often involves a relationship with an organized religion,

interrelationships with others, and the search for the meaning of life. Affiliation and/or









participation in organized religion, however, are not necessary to be considered spiritual

(Burkhardt, 1989; Principe, 1983). Different authors have defined 'spirituality' in

various ways. For the purpose of this discussion, I will use the "spirituality" to describe

the way of life an individual chooses that involves a belief in God or a higher power, a

belief in an after life, and a belief that a higher power influences life's events. I did not

limit this study to 'spirituality' associated with any specific religion or sect.

There has been an increasing interest in the interrelationship of spiritual

involvement, spiritual activity, and health outcomes among the elderly. Koenig,

McCullough, and Larson (2001) give three reasons for this current interest. First,

spirituality and religious affiliation continues to be a central part of people's lives despite

advances in technology, education, and medicine. Second, the United States and other

worldwide populations are aging due to a declining birth rate and greater longevity. In

the future, social programs will have severe financial hardships in providing services for

this population and religious groups may assist in providing some of these services.

There is the possibility that spiritual coping may aid in the prevention of health problems

and thereby assist in health care cost containment. Finally, there is a depersonalization in

the health care delivery system. Individuals seeking medical care and treatment expect

compassion with attention to their social, psychological, and spiritual needs. McFadden

and Levin (1996) summarize recent gerontologic spiritual research as focusing on four

areas of interest: "(a) multidimensional measures, (b) patterns, (c) predictors, and (d)

psychosocial and health related outcomes of religious involvement in older adults and

across the life course" (p. 350).









Summary

Many disciplines including medicine, psychology, and sociology have examined

the relationship of coping and religious affiliation; coping and spiritual beliefs; religious

attendance, and health outcomes like pain, depression, quality of life, mortality, and

morbidity. This investigator believes that the degree of spirituality in the post-surgical

older adult patient has not been considered in evaluating pain report and analgesic

medication use. Achieving adequate pain control is a major goal of professional nursing

care and utilizing spiritual coping may be an important addition in providing non-

pharmocologic pain management.

Specific Aims

The purpose of this study is to explore whether a high degree of spirituality, and

high scores for self-health assessment are correlated with postoperative pain and

analgesic medication use in the acute hospital recovery phase. Currently, there is no

evidence in literature that has examined these variables and their relationship with the use

of postoperative pain medication after total joint arthroplasty. Prior research focused on

relationships of long-term functional rehabilitation, quality of life and spiritual coping.

Using two multidimensional instruments, I propose to address three important aims that

will contribute to the relationship of spirituality, self-health assessment, pain report and

analgesic medication use in the postoperative older adult joint arthroplasty patient.

First, using a multidimensional instrument, this study will investigate whether a

high degree of spirituality is associated with less pain report and medication use in older

individuals receiving primary hip or knee arthroplasty for osteoarthritis. It is the aim of

this research to determine whether older adults receiving a hip or knee arthroplasty with a









high score for spirituality on the Spiritual Involvement and Beliefs Scale (SIBS) will use

less analgesic medication postoperatively.

Second, the Short Form-36 Health Survey that measures general health assessment

will be used to measure self-health in this research. It is the aim of this research to

determine whether older adults with a high score for health self-assessment will use less

analgesic medication after controlling for spirituality.

Finally, the responses for both spirituality and self-health together will be

correlated with analgesic medication.

Hypothesis 1. Older adults with a higher degree of spirituality receiving a hip or

knee arthroplasty for primary osteoarthritis will report less pain and receive less analgesic

medication than those participants with a lower degree of spirituality after controlling for

health self-assessment.

Hypothesis 2. Older adults with high scores on the self-health assessment tool will

report less pain and receive less analgesic medication than those participants with low

scores on the self-health assessment tool after controlling for spirituality.

Hypothesis 3. There will be significantly less analgesic medication used by those

older adults receiving hip or knee arthroplasty who have a high degree of spirituality, and

a high degree of self-health assessment.

Terminology

* Older adult: Age 55 or older

* Epidural: Medications administered to the epidural space surrounding the spinal
cord.

* Extrinsic religious orientation: The pursuit of religious beliefs and religious
practice to feel protected or gaining social status and approval.









* Femoral Nerve Sheath: Medication administered within the femoral nerve sheath
by means of a catheter to anesthetize the femoral nerve.

* Intrinsic religious orientation: The motivation to live the goals set forth by
religious tradition. The way of life often described as "living one's religion" and
using religious practices. The person who has an intrinsic religious orientation may
not be affiliated with a particular religious group.

* Medication Administration Record (MARS): Individual record of medication
administered to a patient during inpatient hospitalization. Each dose of medication
is recorded with the following data: medication name, dosage, time administered,
name of staff administering medication.

* Opioid equi-analgesic conversion: All narcotic medication was converted to
Morphine Sulfate IV equivalents.

* Patient controlled analgesia: Self-administered narcotic analgesia through an
intravenous infusion.

* Religious affiliation: Participating in an organized religious group

* Spirituality: The way of life an individual chooses to live that internalizes a belief
in a higher power. These life thoughts are separate from the body and may involve
God, a belief in an afterlife, and belief that this higher power influences life's
events.

* Spiritual behaviors: Praying, meditation and/or self-reflection, reading spiritual
writings

* Visual Analog Scale (VAS): A pain rating scale adopted by Shands at the
University of Florida to provide accuracy in a patient's pain. The scale is numeric,
one = no pain and

* 10 = the worst pain of life. Patients are asked to rate their pain using numeric
increments 0 to 10.














CHAPTER 2
REVIEW OF THE LITERATURE

This section deals with pertinent papers published during the past 20 years that

address chronic pain, osteoarthritis, lower extremity arthroplasty, and spirituality coping

among the elderly. The first section examines the prevalence of the chronic pain of

osteoarthritis and arthroplasty (focal stimuli), age, gender, and race (contextual stimuli).

The second reviews the relationship of spiritual coping to gender, race, age, and pain.

Presence of Musculoskeletal Chronic Pain and Arthritis Among Older Adults

Pain in the aged adult has become a focus of current gerontologic research. The

elderly have more painful diseases that require more medical visits. The impact of

musculoskeletal conditions on the elderly can be divided into two categories: 1) the

physical and social impact of physical pain (limitations in mobility and social interaction

imposed by these limitations), and 2) the monetary cost involved in the diagnosis and

treatment of these disorders (Praemer, Fumer, & Rice, 1992). Musculoskeletal disorders

after age 65, regardless of gender or racial group, are the most frequently reported

physical impairments, exceeded only by hearing disorders. Surgical intervention,

following failed medical management, is expected to increase dramatically in the next

twenty years (Praemer, et al. 1999). Musculoskeletal functional limitation has a

significant impact on the elderly.

Back and spine disorders are the most frequently reported category of dysfunction,

followed by lower extremity disorders of the hip or knee. Although there are many forms

of arthritis among the elderly, the two most common forms, those with the greatest public









health implications, are osteoarthritis and rheumatoid arthritis. The more prevalent of the

two forms, osteoarthritis, is estimated to affect 20 million people in the United States

(Praemer, et al.1999).

The Relationship of Background Contextual Stimuli and Pain

Age, Pain, and Osteoarthritis

Anderson, et al. (1993) found that 90% of individuals surveyed experienced

chronic musculoskeletal pain. Chronic pain symptoms increased between ages 50-64 and

then gradually declined. After age 60, however, the incidence of lower extremity pain

increased. Compared to younger adults, lower joint pain doubled after age 65 (Anderson,

et al. 1993; Gibson & Helme, 1995). In the Iowa study, Mobily, et al. (1994) observed a

lower incidence of overall pain (p< .0001) among those over 85 years compared to

younger age groups. They also found more than 86% of those surveyed experienced pain

longer than 12 months. Their research is felt to be particularly accurate because of their

large sample size and the longitudinal study design.

Several studies have examined the influence of age on pain sensitivity. Gibson and

Helme ((1995) examined sensitivity to several different forms of experimental pain using

a meta-analysis. Their data suggest a decline in thermal sensitivity after age 60, but do

not show a conclusive difference, or change, in pain sensitivity or pain tolerance. An

earlier study by Helme and Allen (1992) had found that the majority of those surveyed

(79%) agreed that pain was a consequence of the aging process. However, less than half

of these older adults reported pain. The authors concluded that older adults expected to

experience pain as they aged and they did.









Additional research is needed to evaluate both the physiologic and psychological

basis for pain among older adults. More effective management of pain in the older adult

originates in a better understanding of differences and similarities in the pain response.

Gender, Pain and Osteoarthritis

Experimental research has not demonstrated a conclusive difference in pain

perception related to gender. Using heat as a noxious stimulus in humans Paulson,

Minoshima, Morrow, and Casey (1998) concluded there was a gender similarity in the

cerebral and cerebellar activation, but anticipation of the stimulus was more intense in

females.

Keefe, et al. (2000) measured pain, disability, and pain behavior among men and

women with a mean age of 61.1 yrs. They reported significant gender differences in pain

intensity, pain behavior, and physical disability associated with osteoarthritis. Women

had significantly elevated levels (F (1,166)= 4.41, P <0.05) of osteoarthritis pain. They

measured pain behavior, which included stiff movement, rubbing affected joint, and

flexing the joint, in relation to gender. In their analysis women exhibited more pain

behavior than men (F (1,162) = 5.54, P < 0.05). In a recent study of pain and coping,

Affleck et al. (1999) observed that women reported daily osteoarthritis pain and pain

levels 73% greater than males with a similar arthritis diagnosis. Results of these studies

have suggested that among the elderly, there is a difference in pain intensity related to

gender. Further research is necessary to compare noxious pain stimuli, pain thresholds

and intensity studied in younger populations to the older adult.

Age, Gender, and Osteoarthritis

Compared to males, females have twice the incidence of osteoarthritis. Until age

65, however, men report a greater occurrence of osteoarthritis. While men are more









likely to have shoulder, elbow and foot joint pain; women have finger, hip, ankle and

wrist joint pain (Davis, Ettinger, Newhaus & Hauck, 1987). Although specific affected

joint patterns have been identified as following a gender pattern, gender differences do

not contribute to risk factors for the development of osteoarthritis (Davis, et al.

1987;Keefe, et al. 2000; Lawrence, et al. 1998).

Race, Pain and Osteoarthritis

Differences in cultural response to pain have been studied using two methods, non-

experimental using observational methods, and laboratory experimental using painful

stimuli and measuring the response. Zatzick and Dimsdale (1990) were unable to

correlate cultural variations in pain response in their meta-analysis of pain stimuli and of

pain response. They concluded, "there is no evidence suggesting that the

neurophysiology detection of pain varies across cultural boundaries" (p.554). However,

Bates, Edwards, and Anderson (1993) using observational methods to evaluate the

differences in reported chronic pain intensity among seven diverse ethnic groups, found

significant correlations. Additionally, they investigated specific sociodemographic,

medical, and psychological variables that may predict an intra-ethnic group variation in

pain intensity. Bates, et al. (1993) found that pain intensity did not vary among various

ethnic groups because of differences in neurophysiology but was a result of the

biocultural model of pain perception.

European whites have a greater incidence of osteoarthritis than Jamaicans, Blacks,

South African Blacks, Chinese, and Indians (Felson, 1988). Rates for American Indians

are intermediate. There is speculation that individuals of European white descent have a

genetic developmental defect in both the knee and hip joints that facilitates the









development of osteoarthritis. This is supported by greater reporting of joint pain in

whites when compared to blacks or other races (Praemer, et al. 1992).

Total Joint Arthroplasty

Prevalence

The first decade 21st century has been declared the "Bone and Joint Decade" by 35

nations and 44 U.S. states. The number of lower extremity joint procedures has

increased; total knee replacements increased 40.2% during the years 1990 and 1996,

while total hip replacements increased 15.5% for the same years (Praemer, et al. 1999).

Currently more than 425,000 total joint replacements are performed in the United States,

and this number is expected to reach 702,000 by the year 2030 as the baby boomer

generation ages (Praemer, et al. 1999).

The leading reason for joint replacement surgery in the elderly is failure of

conservative medical treatment for end stage arthritic joints. The increase in the number

of aging Americans, and the increase in prevalence of arthritis for this age group along

with a strong desire to remain active have continued to increase the demand for total joint

arthroplasty (Healy, Iorio, & Lemos, 2001). Joint replacement surgery has been shown to

improve pain, functional ability, social function, and quality of life (Aarons, et al. 1996;

McGuigan, et al. 1995; Norman-Taylor, et al. 1996; Ritter, et al. 1995).

The goal of total joint arthroplasty is to recreate the motion of flexion, extension,

adduction, and rotation of the joint that has lost range of motion. This surgical

intervention demonstrates a ten-year success rate for 98 % of elderly individuals while

relieving joint pain and correcting the joint deformity. For patients with bilateral knee

joint end stage arthritis, bilateral joint replacements are often performed at the same time

(Pellino, Preston, Bell, Newton, & Hansen, 2002).









Total hip arthroplasty (THA) is a surgical procedure that replaces a diseased joint

with a synthetic joint using a synthetic acetabulum, femur, and polyethylene liner that are

fixed to bone by cement or bone ingrowths. Total knee arthroplasty (TKA) involves

replacing the femoral and tibia sides of the joint using a long or short stem fixated by

cement. The goal of joint arthroplasty is to improve function with an artificial joint that

improves range of motion and provides pain relief with few surgical complications

(Brander, Mullarkey, & Stulberg, 2001). The decision making process in considering a

candidate for total joint replacement is the degree of radiographic changes and the degree

of functional impairment.

Gender and Arthroplasty

Although women have 1.5-2.0 higher incidence of osteoarthritis, men have more

total knee arthroplasty than women. Katz, et al. (1994) suggests that gender differences

in joint arthroplasty are difficult to evaluate because procedure rates are not reported by

severity of disease. The authors evaluated functional status using a daily living scale that

evaluates the ability to walk several blocks, climb stairs, or take part in vigorous activity.

Greater functional impairment and the use of walking support were reported for most of

the females. The authors suggest that males have earlier surgical intervention for

functional impairment and pain. Praemer, et al. (1999) do report that the number of total

knee replacements for men in 1996 was 1318/100,000 while for women in the same year

it was 928/ 100,000. There is some evidence that suggests women delay surgical

intervention out of fear of surgical failure, death or loss of function postoperatively.

Postponing surgical intervention can also be because of distrust of physicians and

hospitals, a reluctance to take risks and concern about caregiving responsibilities.









Conversely, males most reported concern is the length of rehabilitation time necessary for

the return of joint function (Ritter, et al. 1995).

Race and Arthroplasty

The relationship between race and arthroplasty has been poorly studied. A recent

study in a large county in Texas reported that Hispanics were under represented as

recipients for hip replacement surgery (Escalante, Espinosa-Morales, Del Rincon,

Arroyo, & Older, 2000). In their research, African Americans were also less likely than

Caucasians to receive arthroplasty surgery. Extensive review of research literature on

race and arthroplasty, however, revealed no evidence to suggest a disparity in race and

arthroplasty.

In summary, the number of total joint replacements increases dramatically for both

sexes after age 65 (Praemer, et al. 1999). The effect of this increase can be directly

attributed to the incidence of joint osteoarthritis, chronic pain and functional impairment

(Felson, 1988; Schlesinger, 2001). Women report greater functional impairment for all

activities of daily living and delay arthroplasty for a longer period of time. It is unclear

from previous research reasons for gender differences in osteoarthritis incidence or the

delay for surgical intervention. Previous research only verifies the age related changes of

osteoarthritis, functional impairment and the increase in total joint replacement surgery

for the relief of pain and improvement in physical function.

Spiritual Coping

According to Lazarus, DeLongis, Folkman, and Gruen, (1985), "efficacy

expectations and appraisals refer to cognitions: fear and distress refer to emotional states

that includes cognitions" (p. 776). Stress is regarded as a complex variable and the

individual in his/her personal environment reflects the processing of these variables.









Good health and the absence of chronic pain represent a person's stable environment. An

individual's inability to maintain these environmental variables creates stress and fear.

Through evaluating the stressors and using defense strategies, a coping process will be

used to overcome the disruption in a person's environment (Lazarus et al, 1985). The

older adult uses cognitive interpretation to identify stressful health changes and uses more

defense strategies to cope. Diehl, Coyle, and Labouvie-Vief, (1996) found that compared

to younger people; there was a difference in the use of self-restraint by older adults rather

than aggression to cope with environmental stressors.

Religious behaviors such as prayer, religious service attendance and seeking

spiritual connection, are part of the individual's practice of spiritual or religious coping

(Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, et al. 1998). Researchers

have studied the various spirituality concepts: 1) Religious doctrine; 2) Religious

attendance; and 3) Religious affiliation.

Spirituality includes both the world of experience and the way of life a person lives

that is guided by religious doctrine (Principe, 1983). It is the continuous process of

integrating oneself in current and past experience and the effort of relating to others with

trust and understanding. Spirituality links self with a power greater than the individual.

It is most often associated with a religion that defines the divine and offers ways to relate

to the sacred (McFadden & Gerl, 1990). Fowler describes the persons life spiritual

development as a developmental psychological process that uses cognitive and emotional

synthesis of a sense of meaning and purpose in the life journey (Shulik, 1988).

Interest in research involving the relationship of spirituality and health has been

increasing over the past 15 years. Most existing research has focused on religious









affiliation and health status in hypertension, depression, mortality, and anxiety (Clark,

Friedman, Martin, 1999; Husaini, Blasi & Miller, 1999; Koenig, et al. 1993, 1994). The

examination of a possible therapeutic effect of spirituality in the postoperative joint

replacement patient has not been explored. Levin and Chatters (1998) suggest that in

order to establish a relationship between spirituality and health, research must use

evaluate a measurable medical effect of spirituality or religion and aging. This research

will hypothesize that a positive relationship does exist between the older adult's degree of

spirituality and self-health assessment.

Spiritual Coping and Health

There has been no published research demonstrating a relationship between

spiritual coping, health assessment, and post-surgical pain. Most empirical research has

focused on the relationships of spiritual coping, spiritual beliefs, spiritual involvement

and health outcomes in mental health, hypertension, depression, and anxiety. Matthews,

et al. (1998) reviewed the relationships of religious factors that included religious

attendance and mental health status. The focal areas of mental health status were coping

and recovery from illness. The authors concluded in their review there was strong

support for religious commitment and positive medical outcomes following serious

illnesses e.g. heart disease, cancer. Pargament, et al. (1998) using a spiritual well being

scale found there was a relationship between positive and negative patterns of religious

coping in young and elderly age groups. They measured three diverse sample groups

experiencing stressful life events. The first sample represented Oklahoma City residents

who were evaluated for religious coping after the federal building bombing. The second

sample involved college students who had experienced a significant negative event, such

as a death of a friend or family problems. The third sample group was hospitalized









patients over the age of 55 with moderately severe medical illness. Although, the

participants were of different ages and diverse life event stressors, a positive pattern of

religious coping was found among the three groups. Those participants with positive

religious coping patterns had less psychological anxiety and distress. Those individuals

with negative religious coping were associated with greater emotional distress, e.g.

depression, and reported poorer quality of life. Pargament and colleagues (1990),

extended their religious coping research to more clearly identify the kinds of religious

beliefs, and behaviors that are helpful to individuals as they cope with negative life

events like death, illness, divorce and work related problems. Four separate themes of

religious beliefs and behaviors emerged to further define spiritual beliefs and practice: 1)

belief in a fair and loving God; 2) partnership with God is supportive; 3) positive

outcomes come from using of religious rituals; and 4) search for spiritual and personal

support through religious affiliation. Pargament, et al. (1990) explains nonreligious

avoidance with descriptor items from personal narratives such as "tried not to think about

it," "wished the situation would go away" (p. 818).

Using retrospective demographic data collection, early research that focused on

religious affiliation and health status demonstrated positive relationships between

religious affiliation and various health correlates, such as hypertension control,

depression, anxiety, length of hospital stay and mortality (Koenig, et al. 1993; 1998;

Koenig & Larson, 1998; Meador, et al. 1992). In a review of 20 empirical studies, Levin

& Vanderpool (1990) concluded that religion is therapeutically beneficial in the control

of hypertension. Koenig, et al. (1998) investigated the relationship of religious activities

and blood pressure control among older adults dwelling in communities. They concluded









that religiously active adults displayed lower blood pressures and were more compliant

with prescribed medication. Additionally, they observed a racial difference. The authors

found that although black religious males had higher blood pressures than white religious

males, they were more compliant with medication use for blood pressure control.

Recent research has examined spirituality and functional ability during

rehabilitation. Kim, Heinemann, Bode, Sliwa, & King (2000) examined spirituality using

an intrinsic Judeo-Christian scale of well-being and functional variables among patients

in a rehabilitation hospital. Intrinsic religiousness is defined as the individual's

internalizing a religious belief and living the belief. Individual spirituality scores though

high were not associated with variables of functional recovery such as mobility, and self-

care. Fitchett, Rybarcyk, DeMarco, and Nicholas (1999) found similar results in

postoperative rehabilitation. There was a high degree of spirituality among their patients

who rated their health as poor or very poor. Using a questionnaire that measures church

affiliation, attendance, and spiritual behaviors, the authors were unable to confirm a

relationship between self-health assessment, spirituality, and church activities. Pressman,

Lyons, Larson, and Strain (1990) in a small study of postoperative female orthopedic

patients found significant correlation between church attendance, personal importance of

religion, degree of spirituality, and functional meters walked (r=0.45, df = 27, p<0.05).

This research found that postoperative orthopedic subjects with strong religious beliefs

and practices, and less depression had better ambulatory function at discharge. The

spirituality score was not significantly correlated with ambulatory status independent of

depression. The authors suggest that subjects who are spiritual respond more favorably

to physical therapy because they are less depressed. Hodges, Humphreys, and Eck









(2002) investigated the effects of spirituality on spinal surgery recovery. Using a

spirituality tool that evaluates intrinsic spirituality, they found these subjects to be highly

spiritual (79%). The authors then compared preoperative and postoperative pain scores

with postoperative functional ability. They found no correlation between a high degree

of spirituality and pain scores or functional outcomes.

Spiritual research has investigated the possible relationships of pain, health and

functional recovery. In each study, older adults have a high degree of spirituality on

various measurement tools, but only one study reported a significant correlation that

included a finding of less depression. The investigation of spirituality and health has not

been evaluated using consistent measures of spirituality scales and postoperative

population groups. Most current research has observed possible religious affiliation,

spiritual beliefs and functional status.

Relationships between Spiritual Beliefs, Gender and Race

Few empirical studies have examined pain, gender, and racial relationships

(Affleck, et al. 1999). Research regarding utilization of health services demonstrated a

positive correlation between utilization and religious attendance in elderly male patients

60+ years of age. Increased attendance at religious services prior to hospitalization

correlated with a shorter hospital stay and fewer hospital admissions (Koenig & Larson,

1998).

Past research concentrated on religious coping behaviors, including religious

affiliation, beliefs and involvement. Research findings suggest that many older adults use

spiritual coping in various stressful health situations and that this coping has had a

beneficial effect. Further investigation is needed using spiritual measures to examine if









there is a spiritual coping adaptive effect in the management of older adult postoperative

pain.

Roy Adaptation Model-Based Research

In 1976, Sister Callista Roy's theory of an adaptation model for nursing was

presented to guide nursing education in the United States. The theory was later revised to

address the middle range or practice level theory relevant to patient care in nursing. In

1999, a new model of the Human Adaptive system was introduced to clarify the

understanding of the various components of the theory and to extend it into clinical

practice (Roy & Andrews, 1999). Roy defines the purpose of nursing practice as the

promotion of the ability of human adaptive systems to adjust effectively to changes in the

environment and to the individual's ability to modify their environment (Roy &

Andrews, 1999). Roy's theory contains scientific and philosophical assumptions that

describe successful human coping in changing environments. According to Roy, the

adaptation of the human system is based on scientific assumptions that include: 1)

meaning is necessary for person and environment integration; 2) thinking and feeling is

necessary for awareness; 3) people have a commonality of patterns and relationships; 4)

adaptation results from the integration people and their environment. Further, the

adaptation concept includes Roy's philosophical assumptions: 1) relationships include a

higher power and the world; 2) people use the ability of faith; 3) God is observed in

diversity of creation, and is the destiny of creation.











MODEL DIAGRAM OF RESEARCH QUESTIONS USING ADAPTATION MODEL
(ONTF..TTI Al. FOC L. COMPENSATORY ADAPTIVE
STIMULI STIMULUS LIFE PRO(_ ESiar MOUDES





DECREE OFIN PI
/E / I _SPIRITUALITY


TOTAL JOINT
RACE / ARTHaOPLASTY
FOR
OSTFOARTHMlTIS
AND CHRONIC
PAIN











Figure 2-1. Model Diagram of Research Questions
SELF-
ASS3E9SMNE .-ANALESIC
II I_ EALT H MEDICAW-nO USE *-
STATUS
COPING






Figure 2-1. Model Diagram of Research Questions

Roy Adaptation Model Gerontologic Research

Roy describes the adaptive process as adjusting effectively to environmental

changes using cognitive interpretation and coping processes to maintain an integrated

life. In this model, compensatory life processes are spiritual coping and health self-

assessment. These regulatory processes provide an adaptive response for less pain.

Roy's adaptation model has been used mainly with children and adults in a hospital

environment. One gerontologic study has used the Roy adaptation model to evaluate a

coping process and the concept of self-consistency. Roy believes the concept of personal

self is a combination of self-consistency, the moral-ethical spiritual self and the self-ideal

(Roy & Andrews, 1999). Zhan (2000) used the Roy Adaptation Model to study

adaptation and coping with severe hearing loss in 130 elderly adults. Health status and

coping data were analyzed for positive relationships between cognitive coping and self-









consistency. There was a positive correlation between those who rated their health as

good or excellent and self-consistency. The variance in self-consistency was the result of

cognitive coping processes. Three cognitive processes; clear focus and method, knowing

awareness, and self-perception were most significant (36.97 (p< .001, df =5).

There is support for the use of the Roy Adaptation Model in gerontological

research to evaluate spiritual coping and adaptation to pain. Successful adaptation to

environmental changes is necessary to return to good health and well being as people age.

Summary

Chronic pain in the aged adult is both a physical and emotional experience.

Current research suggests that the use of pharmocologic and non-pharmocologic methods

in the elderly may reduce chronic pain. However, some research findings suggest that the

use of specific non-pharmocologic interventions such as spiritual behavior, religious

attendance, and spiritual beliefs are inconclusive in providing relief from the negative

effects of chronic illness and pain. This research study will evaluate relationships

between spirituality and analgesic medication use after total joint arthroplasty in older

adults.

Measurement of the degree of spirituality and health will evaluate the effectiveness

of coping with postoperative pain in the older adult. This research will provide

quantitative data to provide a framework for evaluating older adult's spirituality as an

alternative non-pharmocologic intervention in postoperative pain management.














CHAPTER 3
METHODS

Research Design

This research examines the relationship of older adults' spiritual beliefs, and self-

health assessment and analgesic medication use during the first three days after total joint

replacement surgery. A correlational convenience design was used to investigate the

questions in a sample of surgical candidates scheduled for hip and knee joint arthroplasty.

Using the Roy Adaptation Model, this study examined relationships between total joint

arthroplasty for osteoarthritis, chronic pain, the degree of spiritual beliefs, spiritual

involvement, self-health assessment and the health outcome of postoperative analgesic

medication use. Participants for this research came from a socially diverse area in North

Florida.

Controls

Three orthopedic surgeons from the University of Florida College of Medicine,

Department of Orthopedics performed all of the total joint arthroplasty. To control

variations in general anesthesia technique, one supervising anesthesiologist planned each

participant's anesthetic care. Participants chose his/her preferred method of

postoperative pain control prior to surgery. Choices included regional anesthesia, Patient

Control Analgesia (PCA), or PRN dosing. Preoperative patient education and anesthesia

evaluation was done according to the standard of care established by the University of

Florida College of Medicine.









Inclusion criteria:

1. 55 years of age or older

2. Primary hip or knee joint arthroplasty

3. Osteoarthritis of the hip or knee joint as demonstrated by radiographic exam and
orthopedic surgeon's diagnosis as documented in the medical record

4. Failed medical management of chronic joint pain

5. Inclusion regardless of comorbidity status

6. Candidates for hip or knee arthroplasty

Power Analysis and Sample Size

An estimate of statistical power was determined using the G power computer

software to calculate the required sample size. A total of 115 participants were consented

and completed the study. The sample size was based on a formulation of 80% power, at

least six independent variables, an effect size of 0.15 (R-squared= 0.13) with a

significance of 0.05 for a two-tailed test. The G power computer software was used to

calculate the required sample size (Erdfelder, Faul, & Buchner, 1996).

Procedures

The Principle investigator of this study contacted the chairman of the Orthopedic

Department and presented a description of the study. The chairman then provided a

signed letter of agreement acknowledging awareness of this study (See Appendix A).

In the original protocol, I planned control variation in surgical technique using only

patients scheduled with one orthopedic surgeon. A total of 27 patients were enrolled

from July, 2003 until January, 2004. During this enrollment period, however, the

identified surgeon reduced the number of total joint surgeries he performed per month in

order to fulfill administrative duties. In January, 2004, the investigator met with

committee members to explore adding two additional surgeons in order to attain within a









reasonable length of time a number of subjects months adequate for a power analysis.

After appropriated discussions, two additional orthopedic surgeons agreed to help. They

were each provided a copy of the protocol and informed consent. A revision that

included the two additional orthopedic surgeons was submitted and approved by the IRB

in January, 2004.

Protection of Human Subjects

University of Florida Institutional Review Board (IRB) approval was obtained prior

to participant enrollment or data collection (See Appendix B for final approval, revised

approval and extension approval forms). A revision to include the additional orthopedic

surgeons was submitted and approved in January, 2004. A final IRB extension was

submitted June, 2004 to extend the research study from July, 2004 until July, 2005.

Method

Patients scheduled for surgery are scheduled in the pre-surgical center for an

examination by an ARNP to determine their suitability for anesthesia. From this group

the principal investigator identified potential subjects for study. Subjects who met the

inclusion criteria and agreed to participate in the study were given a verbal description of

the study, confidentiality assurance, and possible risks of their participation. Those

patients who expressed willingness to participate completed two questionnaires. The

questionnaires took approximately 20 minutes to complete during their pre-operative

visit. The principal investigator and each subject signed a copy of the informed consent.

A copy of the signed informed consent was given to the participant for their individual

records. The principal investigator verbally asked each subject if they had additional

questions regarding their participation in this research study prior to their discharge from

the pre-surgical center.









A key containing the participant's name, and confidential code was developed.

Informed consents and questionnaires were coded with the participant's confidential code

and are kept in a locked file cabinet in the principal investigator's office.

Measures

Demographic data. Age, gender and ethnicity were coded using a coding key

(see Appendix G). Demographic data was entered on an Excel spreadsheet after

enrollment. There was no missing demographic data.

Preoperative Questionnaire Measures

Indicator of spirituality

The Spiritual Involvement and Belief Scale- (Revised (SIBS-R) Hatch, Burg,

Naberhaus, & Hellmich (1998) evaluates a broad range of intrinsic spiritual content from

ability to find meaning in life to spiritual writings. Designed for use with individuals of

all religious and non-religious traditions that include Christian, Judeo, Hindu, Islam and

Atheist. This instrument differs from other spiritual measurement tools in that it is not

limited to individuals with a Judeo-Christian tradition.

For the purpose of this study one question was selected to evaluate participants'

spirituality. Two groups were created using the response to the question, "How spiritual

a person do you consider yourself?" Subjects were asked to rate themselves on a scale of

1 to 7 with 7 meaning "the most spiritual". Those groups who rated themselves 5, 6, or 7

were considered highly spiritual and coded as 1. Those who rated their spirituality as

1,2,3, or 4 were considered less spiritual and coded as 0

Indicator of self-health assessment

The Rand SF-36 Health Status Questionnaire measures physical functioning, social

functioning, role functioning (physical problems) and role functioning (emotional









problems). Additionally, the instrument measures mental health, fatigue, pain, and

general health.

One question, "In general would you say your health is", was used to create two

groups for the analysis. If a participant answered good, very good or excellent, their

response was considered as a high self-health assessment and coded as 1. If their

response was fair or poor, their self-health assessment was considered a low score and

coded as 0

Questionnaire data. Using the patient's confidential code all questionnaire data

was entered using an excel spreadsheet. Missing data on questionnaires was entered as a

dot.

Indicator of diagnosed osteoarthritis. A diagnosis of osteoarthritis was recorded by

the orthopedic surgeon and is available in each individual participant's medical record.

The diagnosis was verified with the individual's pre-surgical history and physical

assessment.

Indicator of ethnicity

Ethnicity was obtained from the patient's admission record. The admissions

department routinely obtains ethnicity information during a patient's initial interview

prior to entering the hospital.

Postoperative Data Collection Procedures

Indicator of pain scores. Individual postoperative pain scores were obtained from

the individual's medical record. Daily pain scores were recorded and averaged for three

days postoperatively. Additionally, a daily median pain score was recorded for this same

interval. Pain was evaluated using the Visual Analog Scale (VAS) that evaluates pain

intensity numerically using a 0 to 10 measurement (0= no pain, 10= worst pain). The









VAS instrument is used with all age groups and is the approved pain scale for use at

Shands Hospital at the University of Florida.

Analgesic medication use. Medications dispensed during a patient's hospitalization

are records in the Medication Administration Record (MARS). The MARS documents

each dose of medicine administered by nursing personnel. This medication record

contains the medication name, date, time, dosage and initials of hospital personnel

administering the medication. Individual Medication Administration Records (MARS)

were evaluated for the use of narcotic analgesic medication for every participant. An

Opioid equi-analgesic conversion table was used and all opiates were standardized to

morphine sulfate equivalents. For example, 1.5 mg IV Hydromorphone = 100 mcg

IV/SC Fentanyl = 20 mg P.O. Oxycodone = 10 mg IV Morphine (Pasero, Portenoy &

McCaffery, 1999). Total IV Morphine Sulfate equi-analgesic conversion was recorded

for each postoperative day for three days.

Regional anesthesia use. Regional anesthesia techniques such as epidural, Femoral

Nerve Sheath Catheters, and Psoais Compartment Catheters provide postoperative pain

relief by blocking nerve conduction with local anesthetics, thereby blocking the

transmission of pain (Pasero, Portenoy, & McCaffery, 1999). The use of a local

anesthestic provides a sensory and motor blockage. The epidural regional anesthesia

technique occasionally requires the use of an opioid agent in addition to a blocking agent.

The use of an opioid agent is recorded on a separate analgesic document in the patient's

medical record. The placement location of regional anesthesia is recorded on a separate

document located within the patient's medical record.









Medical record data. Medical record data collected included surgical site,

anesthesia data, pain scores and analgesic medication used. A form was developed (see

appendix) to collect data from the participant's medical record after discharge. Medical

records were requested using a Request for Records review and Shands at the UF

Research Chart Request forms. An average of 4-20 charts were requested each time;

medical records usually required two weeks to be assembled. Several delays were

experienced in obtaining medical records that included research medical records

personnel vacation days, sick days, and incomplete delivery of records. One medical

record has been lost. Two records are incomplete with medication records missing.

The Medical Record Department requires that all data and chart review must be

preformed in the records department. Using the coding key, data was recorded on the

case coding form. Pain scores were documented as average scores and median pain

scores. All opioid medications were converted to Morphine Sulfate IV equi-analgesics

and recorded. Surgical site, anesthesia type, regional anesthesia, general anesthesia were

coded using the coding key.

Data Analysis

Data obtained in the postoperative period were entered on an Excel spreadsheet.

Analysis used SPSS statistical software, Version 11 for Windows. Demographic data for

spirituality, self-health assessment, age, gender, pain scores, and analgesic medication

use were analyzed to generate descriptive statistics using mean scores and frequencies

The hypotheses were tested with analysis procedures using Pearson's correlation

coefficient, T-Test and ANOVA with significance levels of 0.05. Correlations measure

how variables are related and measure their linear association. Frequencies and mean

scores were analyzed for all demographic data, age, gender, operative site, physician,






32


regional anesthesia and analgesic medication use. Individual survey questionnaire items

were analyzed using frequency and percentage of individual participant response.

Summary

This chapter presented research design, sample inclusion, power analysis,

methodology, and data collection procedures for this study. Data analysis methodology

for research hypotheses was discussed.














CHAPTER 4
RESULTS

A description of the participants and the results of this descriptive study are

presented in this chapter. The results are examined in relation to the three hypotheses.

This study took place at Shands at the University of Florida. Subjects were recruited as a

convenience sample that included only persons that met the inclusion criteria. Informed

Consent and questionnaire data were collected in the pre-surgical anesthesia clinic.

Demographic data, pain scores and medication use were obtained from the subject's

medical record after hospital discharge. All data was computed using the SPSS statistical

software, version 11 for Windows. Statistical significance was set at p < 0.05.

Sample Characteristics

A total of 126 potential subjects who met the inclusion criteria were approached to

participate in the study. Eleven potential participants declined to participate. Three

stated they were "tired of filling out paperwork", two did not want to participate in any

research and one did not believe in spirituality. Five did not express a reason for refusing

participation. None of the potential research participants expressed any fear of an

adverse event by participating in this study. All subjects who agreed to participate signed

an informed consent and completed the two questionnaires in the pre-operative anesthesia

center. At the end of the study one subject's medical record was missing from the

Medical Records Department and after a detailed search was considered lost. One

subject's Medication Administration Record was missing from the medical record and









presumed lost. All other participants' medical records were complete at the end of the

data collection period.

One hundred and fifteen subjects who met the inclusion criteria were consented.

The mean age of the sample was 67.70 (SD = 8.23). Seventy- four (64.3 %) of the

participants were female and 41 (35.7%) were males. The majority of the participants

were Caucasian (n = 111), followed by Hispanic (n = 2) and African American (n = 1).

All participants were diagnosed with severe osteoarthritis and had failed

conservative medical management. Right total knee arthroplasty was the joint

replacement most frequently performed at 35% (n = 35), followed by left total knee

arthroplasty at 27.8% (n = 32), right total hip arthroplasty 18% (n=18), left total hip

arthroplasty at 13.9% (n =16), and bilateral total knee arthroplasty at 10.4% (n = 12).

Regional Anesthesia

Forty-six percent (n = 56) of the participants chose a femoral nerve sheath for post-

operative pain control, while 25.2% (n = 29) chose an epidural, 3.5% (n = 4) chose a

psoas compartment sheath, and 1.7% chose a continuous spinal. Patient controlled

analgesia (PCA) was used by 67% (n = 77) of subjects. The PCA group includes some of

the subjects who received a femoral nerve sheath. All other participants selected "as

needed" analgesia for postoperative pain control.

Anesthesia Technique During Surgery

General anesthesia was administered to 100 participants (87%) followed by

continuous spinal at 4.3% (n = 5), followed by managed anesthesia care at 2.6% (n=3).









Analysis of Data in Relation to the Hypotheses

Hypothesis 1

Hypothesis 1 stated that older adults with a high degree of spirituality receiving hip

or knee arthroplasty for primary osteoarthritis would report less pain and receive less

analgesic medication than those participants with a lower degree of spirituality after

controlling for health self-assessment.

The Pearson Correlational analysis as shown in Table 3, demonstrated there was no

significant correlation between spirituality response, self-health questionnaire response

and the following variables: age (r = -0.02, p = 0.84), average pain scores day one (r=

0.01, p = 0.92), average pain scores day two (r = 0.02, p = 0.84), average pain scores day

three (r = 0.03, p = 0.78) and analgesic medication use (r = -0.04, p = 0.69). A partial

correlation coefficient controlling for the self-health assessment score was then analyzed

(See Table 4) and there were no significant correlations between spirituality, and the

variables: age (r = -0.05, p = 0.60), pain day one (r = 0.53, p = 0.59), pain day two (r =

0.06, p = 0.53), pain day three (r = 0.06, p = 0.56) and pain medication (r = -0.02, p =

0.81). Hence, Hypothesis 1 was rejected.

Hypothesis 2

Hypothesis 2 stated that older adults with a high score on the high self-health

assessment tool would report less pain and receive less analgesic medication than those

participants with a low score on the self-health assessment tool after controlling for

spirituality.

The Pearson Correlation found there was a significant correlation as shown in

Table 5 between the variable for health on the Short Form-36 Health Survey and age (r =

0.23, p = 0.02), average pain scores day one (r = -0.31, p = 0.00), day two (r= -0.29, p =









0.00) and day three (r = -0.22, p = 0.03). There were similar results for days one, two,

and three and median pain scores. However, there was no significant correlation between

the variables, analgesic medication use (r = -0.11, p = 0.23) or high spirituality (r = 0.13,

p = 0.17) as shown in Table 5.

A Pearson Partial correlation for health assessment while controlling for spirituality

was analyzed. There was a statistically significant correlation for the following variables:

age (r = 0.23, p = 0.02), pain scores on day one (r = -0.31, p = 0.00), day two (r = 0.29,

p = 0.00), day three (r = -0.22, p = 0.02). There was no significance for less analgesic

medication use (r = -0.11, p = 0.26) as shown in Table 6. The results confirmed

Hypothesis 2 for pain, but rejected it for analgesic medication use.

Hypothesis 3

Hypothesis 3 stated that there would be less analgesic medication used in those

older adults receiving hip or knee arthroplasty who had a high degree of spirituality

involvement and beliefs and a high score on the self-health assessment tool.

An ANOVA regression was used to determine if there was an interaction between

good to excellent health and a high degree of spirituality. The relationship was not

significant (F = 1.04, p = 0.38). Further analysis a T-Test was used to determine if there

was a difference in the average analgesic medication use between the high spirituality

group and the good to excellent self-assessed health group (Ms = 7.63 and 8.49

respectively). Hypothesis 3 was rejected.

Additional Findings

For the purpose of this research, one question rating degree of spirituality was used

from this scale. The SIBS tool was satisfactory and demonstrated a Cronbach Coefficient

Alpha 0.94 Raw Score. Each participant completed the 39-item questionnaire and there









were a many positive responses to specific questions on the spirituality and beliefs scale.

For example, on the item "spiritual health contributes to physical health," 70.4% agreed

or strongly agreed. Most participants considered themselves spiritual when asked to rate

their spirituality on a scale of 1 to 7 (with "7" being the most spiritual). Participants used

religious coping such as hope, personal relationship with a greater power than self, and a

belief that prayer changes things. A high number of participants (77%) wanted others to

pray for them during their illness. More than 70% of the respondents felt that spiritual

health contributes to physical health. Additionally, 95 or 82.6% of the participants

always or almost always make an effort to apologize when they do wrong to someone.

Overall scores on the SIBS instrument reflected a positive relationship with a higher

power, prayer, a belief in an after life, and continued spiritual growth (see Table 7).

Participants expressed difficulty with the SIBS questionnaire and often said, "this is

too hard to answer" or, I have to think a lot". However, no participant asked for

clarification of a SIBS question.

The Short Form-36 Health Survey

For the purposes of this research participant response to the question "In general

would you say your health is: excellent, very good, good, fair, poor" was used for

analysis. Participants answered the 11-item self-assessment tool that queried physical

and emotional function. It is of interest that most were "limited a lot" for vigorous and

moderate activities. Daily activities such as walking, bending, kneeling and stooping had

the highest response for "limited a lot". Simple activities such as dressing and bathing

were least limited. The tool seemed easier than the SIBS for participants to complete and

there were no missed questions.









Table 1. Frequency and Percent of Variables
Variable Frequency Percentage
Sex
Male 41 35.7
Female 74 64.3

Ethnicity
White 111 96.5
African American 1 .9
Hispanic 2 1.8

Operative Site
No response 2 1.7
Left Total Hip Arthroplasty 16 13.9
Right Total Hip Arthroplasty 18 15.7
Left Total Knee Arthroplasty 32 27.8
Right Total Knee Arthroplasty 35 30.4
Bilateral Total Knee Arthroplasty 12 10.4

Orthopedic Surgeon
Surgeon #1 81 70.4
Surgeon #2 23 20.0
Surgeon #3 11 9.6

Regional Anesthesia
No Regional 22 19.1
No Response 1 .9
Epidural 29 25.2
Femoral Nerve Sheath 56 48.7
Psoas Compartment Sheath 4 3.5
Continuous Spinal 2 1.7
Spinal 1 .9

Patient Controlled Analgesia
No Response 3 2.6
NoPCA 35 30.4
PCA 77 67.0

Anesthesia Type
No Response 2 1.7
GETA 100 87.0
Spinal 5 4.3
MAC 3 2.6
Continuous Spinal 5 4.3









Table 2. Summary Measures of Variables


Variable
Age
Av. Pain
Scores day 1
Av. Pain
Scores day 2
Av Pain
Scores day 3

Median Pain
Scores day 1

Median Pain
Scores day 2
Median Pain
Scores day 3
Health Self-
Assessment
Spirituality


Mean
67.70
3.34

2.28

2.24


2.97


2.01

2.11

0.82

0.69


Std. Dev
8.23
1.99

2.04

2.15


2.67


2.31

2.38

0.39

0.46


Minimum
55.00
0


Maximum
86.00
9.13


7.20

9.20


9.75


9.00

9.00

1.00

1.00


Table 3. Pearson Correlation Coefficients-Spirituality and Variables with No
Adjustments
Variables r value p value n
Age -0.02 0.84 111
Pain Day 1 (average) 0.01 0.92 109
Pain Day 2 (average) 0.02 0.84 108
Pain Day 3 (average) 0.03 0.78 103
Pain Day 1 (median) 0.01 0.91 109
Pain Day 2 (median) -0.03 0.75 108
Pain Day 3 (median) 0.10 0.30 102
Analgesic Medication Use Day 1-3 -0.04 0.69 109




Table 4. Pearson Partial Coefficients-Controlling for Health Assessment


Variables
Age
Pain Day 1 (average)
Pain Day 2 (average)
Pain Day 3 (average)
Pain Day 1 (median)
Pain Day 2 (median)
Pain Day 3 (median)
Analgesic Medication Use Day 1-3


r value
-0.05
0.05
0.06
0.06
0.05
0.01
0.13
-0.02


p value
0.60
0.59
0.53
0.56
0.63
0.92
0.18
0.81









Table 5. Pearson Correlation Coefficients-Health Self-Assessment and
No Adjustments


Variables
Age
Pain Day 1 (average)
Pain Day 2 (average)
Pain Day 3 (average)
Pain Day 1 (median)
Pain Day 2 (median)
Pain Day 3 (median)
Analgesic Medication Use Day 1-3
Spirituality


r value
0.23
-0.31
-0.29
-0.22
-0.26
-0.30
-0.21
-0.11
0.13


Variables with


p value
0.02
0.00
0.00
0.03
0.01
0.00
0.04
0.23
0.17


Table 6. Pearson Partial Coefficients-Health Self-Assessment and Variables Controlling
for Spirituality
Variables r value p value n
Age 0.23 0.02 108
Pain Day 1 (average) -0.31 0.00 106
Pain Day 2 (average) -0.29 0.00 105
Pain Day 3 (average) -0.22 0.02 100
Pain Day 1 (median) -0.26 0.01 106
Pain Day 2 (median) -0.30 0.00 105
Pain Day 3 (median) -0.22 0.03 99
Analgesic Medication Use Day 1-3 -0.11 0.26 106









Table 7. Frequencies and Percentages for Self- Reported SIBS Questionnaire (N=115).
Answers reflect Agree or Strongly Agree scores only Frequency Percentage
except for questions that are reverse score negatively
worded items. These items were scored disagree or
strongly agree.
(1) I set aside time for meditation and/or self- 51 44.3
reflection.
(2) I can find meaning in times of hardship. 67 58.3
(3) A person can be fulfilled without pursuing active 43 37.4
spiritual life. (disagree/strongly disagree)
(4) I find serenity by accepting things as they are. 53 45.0
(5) Some experiences can be understood only through 64 55.6
one's spiritual beliefs
(6) I do not believe in an afterlife. 70 60.9
(disagree/strongly disagree)
(7) A spiritual force influences the events in my life. 70 60.9
(8) I have a relationship with someone I can turn to 69 60
for spiritual guidance.
(9) Prayers do not really change what happens. 79 68.7
(disagree/strongly disagree)
(10) Participating in spiritual activities helps me 70 60.9
forgive other people.
(11) I find inner peace when I am in harmony with 68 59.2
nature.
(12) Everything happens for a greater purpose 70 60.9
(13) I use contemplation to get in touch with my true 43 37.4
self.
(14) My spiritual life fulfills me in ways that material 62 53.9
possessions do not. (This question is missed by 25
or 21.7% do to its position in the questionnaire)
(15) I rarely feel connected to something greater than 62 53.9
myself. (disagree/strongly disagree)
(16) In times of despair, I can find little reason to hope. 80 69.6
(disagree/strongly disagree)
(17) When I am sick, I would like others to pray for 89 77.4
me.









Table 7. Continued
Answers reflect Agree or Strongly Agree scores only Frequency Percentage
except for questions that are reverse score negatively
worded items. These items were scored disagree or
strongly agree.
(18) I have a personal relationship with a power greater 81 70.4
than myself
(19) I have had a spiritual experience that greatly 57 49.6
changed my life
(20) When I help others, I expect nothing in return. 98 84.2
(21) I don't take time to appreciate nature. 70 60.9
(disagree/strongly disagree)
(22) I depend on a higher power. 70 60.9
(23) I have joy in my life because of my spirituality 74 64.3
(24) My relationship with a higher power helps me 69 60.0
love others more completely.
(25) Spiritual writings enrich my life. 61 52.1
(26) I have experienced healing after prayer. 47 40.9
(27) My spiritual understanding continues to grow. 74 64.3
(28) I am right more often than most people. 34 28.0
(disagree/strongly disagree)
(29) Many spiritual approaches have little value. 62 53.9
(30) Spiritual health contributes to physical health. 81 70.4
(31) I regularly interact with others for spiritual 52 45.2
purposes.
(32) I focus on what needs to be changed in me, not 75 65.2
what needs to be changed in others.
(33) In difficult times, I am still grateful. 91 79.1
(34) I have through a time of great suffering that led to 51 44.3
spiritual growth.
The following questions were scored using only the response always or almost always
(35) When I wrong someone, I make an effort to 95 82.6
apologize.
(36) I accept others as they are. 75 65.2
(37) I solve my problems without using spiritual 25 21.7
resources.









Table 7. Continued.
Answers reflect Agree or Strongly Agree scores only Frequency Percentage
except for questions that are reverse score negatively
worded items. These items were scored disagree or
strongly agree.
The following questions were scored using only the response always or almost always
(38) I examine my actions to see if they reflect my 49 42.6
values.
The following question was scored 1-7 with "7" being the most spiritual. Scoring for this
question used response 5,6,7.
(39) How spiritual a person do you consider yourself? 50 66.9


Table 8. Frequencies and Percentages Questions that Indicated Ratings for General
Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey
questionnaire (N=115).
Questions Frequency Percentage
(1) In general would you say your health is: 94 81.73
response: excellent, very good, good

(2) Compared to one year ago how would you rate
your health in general now?
Much better 9 7.83
Somewhat better 18 15.65
About the same 61 53.04
Somewhat worse now 23 20.00
Much worse now 4 3.48

(7) How much bodily pain have you had during
the past 4 weeks?
No response 2 1.74
None 0 0
Very Mild 14 12.17
Moderate 36 31.30
Severe 46 40.00
Very Severe 17 14.78

Additional findings included the increased use of regional analgesic techniques

during the last six months of this research. Concurrent research by another investigator

enrolled some of these same participants receiving total knee arthroplasty in a study using

femoral nerve sheath technique to treat postoperative pain. This investigator examined









the pain report outcomes for two of the most frequently used regional analgesia methods

of postoperative pain control: epidurals and femoral nerve sheath catheters. Analysis of

these two methods compared the mean pain scores on postoperative days one, two and

three. Both techniques had lower mean scores for pain scores on days one, two and three

when compared to no regional technique. The epidural provided the lowest mean score

day one (M= 2.74) compared to the femoral nerve sheath on day one (M= 3.17). Those

participants using PRN analgesia and no regional technique had the highest mean pain

score on day one (M=4.25). On day two, the femoral nerve sheath provided the lowest

mean pain score (M==1.82). On day three all of the regional analgesia had been

removed, but the mean pain scores for those persons who received regional analgesia

remained similar to days one and two. On all three days the PRN analgesia group had the

highest mean pain score (Ms= 4.25, 2.90, and 2.94, respectively).

In summary, these findings demonstrated that participants in this study were in

moderate to severe pain and had functional limitations preoperatively, but described

themselves as in good to excellent health and very spiritual. The use of regional

analgesia for postoperative pain control did lower pain scores for all days when compared

to those who did not receive a regional technique.














CHAPTER 5
DISCUSSION

The purpose of this study was to examine the relationships between the degree of

spirituality and high scores on a self-health assessment questionnaire with three

postoperative outcomes after hip or knee joint arthroplasty. Specifically, this study

examined the relationships between a high degree of spirituality, a high score for

individual self-health assessment and pain report and analgesic medication use for three

days after total joint replacement surgery. The hypothesized relational statements were

based on the need for quantitative data collection measuring the relationships between

spirituality, health assessment, pain report and analgesic medication use. There is no

previous empirical research that has examined these relationships in the postoperative

arthroplasty patient. The study sample consisted of 115 participants scheduled for hip or

knee arthroplasty in a large Southeastern teaching hospital. This chapter will present a

discussion of (1) research findings, (2) conclusions, (3) research strengths and

weaknesses, and (4) implications for nursing practice.

Research Findings

This section will discuss sample characteristics, followed by study of findings as

they related to the research questions.

Sample Characteristics

One hundred and fifteen older adults who were scheduled for hip or knee total joint

arthroscopy consented to participate in this study. All of the participants were recruited

from the pre-surgical anesthesia center of a large teaching hospital. In this convenience









sample, the participant ages ranged from 55 to 86. The average age was 67.70. There

were 41 males and 74 females enrolled in this study. This finding is somewhat less than

the 2:1 ratio females to males in osteoarthritis prevalence as reported by other researchers

(Davis, Ellinger, Newhaus, & Hauck, 1987). Participants described their generalized

body pain as severe or very severe (55%) during the four weeks prior to their scheduled

surgery, but self-assessed their health as excellent, very good or good (81.73%).

Anderson, et al. (1993) and Mobily, et al. (1994) reported similar pain report among older

adults. This research found that functional abilities were severely limited for vigorous

activity such as participating in strenuous sports, lifting heavy objects, vacuuming,

playing golf walking several blocks, bending, stooping and climbing stairs while more

moderate activities such as lifting groceries, bathing and dressing were "limited a little".

Praemer, Furner, & Rice, (1992) and Salmon, et al. (2001) found similar functional

limitations in osteoarthritis patients.

Ethnicity could not be examined due to the low numbers of African Americans and

Hispanics enrolled in this research. Felson (1988) similarly found that greater numbers

of European whites have osteoarthritis than other ethnicities and this may account for the

differences observed in this study. Only one African American and two Hispanics were

enrolled in this research. Socioeconomic status may have been a factor in the low

number of other ethnic groups seeking joint replacement. However, socioeconomic

status was not considered in this research.

Spirituality, Pain Report and Analgesic Medication.

The first research question examined the relationship of a high degree of

spirituality, postoperative pain scores and analgesic medication use. One research









question was used from the SIBS questionnaire. Two groups of participants were created

using one research question from the SIBS questionnaire. Those with high scores for

spirituality were considered highly spiritual. The majority (69.4%) of the respondents

were highly spiritual. A partial correlational analysis was used to identify a relationship

between a participants' high spirituality and the variables, age, pain report for three days

and analgesic medication use postoperatively, controlling for self-assessed health. There

was no relationship for spirituality and the variables. Therefore, hypothesis 1 was

rejected. Participants who have a high degree of spirituality did not tend to have less pain

and did not tend to use less analgesic medication postoperatively. Although there was a

high participant response to spirituality, the possibility of spiritual coping did not tend to

influence pain or pain medicine use after joint replacement surgery.

Health Self-Assessment, Pain Report and Analgesic Medication Use

It was hypothesized that participants who consider themselves healthy will report

less pain and use less analgesic medication postoperatively. The health variable "In

general would you say your health is: excellent, very good, good" was used to identify

those participants with a high score on health assessment. Of the participants, 81.7%

rated their health in this positive way. Correlation analysis found that persons who

considered themselves healthy tended to have less pain on each day postoperatively but

they did not tend to use less pain medication. Therefore, there was no association

between high health scores and less pain medication use. Further analysis using a partial

correlation controlling for the spirituality variable, found similar results; a healthy

assessment was related to less pain for the three days postoperatively and had no

relationship with the amount of pain medication.









In summary, participants who rated self-health as good, very good or excellent

tended to experience less pain during the first three days postoperatively. However, these

same participants did not tend to use less pain medication. Research question 2 was

accepted for less pain, but rejected for less pain medication use.

Impact of Health Assessment and Spirituality on Pain Reports and Analgesic Medication
Use

Lastly, it was hypothesized that participants who considered themselves to be very

spiritual and healthy would use less analgesic medication during their postoperative

recovery. A regression analysis was used to determine possible interactions between

health assessment and spirituality and analgesic medication use. There was no

relationship between the variables and pain medication. A further T-Test was used to

determine if there was a difference between the high spirituality and the high self health

assessment groups in analgesic medication use. The T-Test found no mean difference

between the two groups.

Therefore, Hypothesis 3 was not accepted. Those participants who self-rated their

health as good, very good or excellent and considered their spirituality as high did not

tend to experience less pain or use less pain medication than did the other research

participants.

Conclusions

Although participants reported moderate to severe bodily pain and a decrease in

functional activity on a health questionnaire, they considered themselves to be healthy.

There was a relationship between self-health and pain for the first three days after

surgery. It demonstrated that how a person views their health contributes to the amount

of pain they experience after joint replacement. Additionally, less pain experienced did









not mean less pain medication used. There has been no previous research evaluating

relationships between how healthy an individual feels and the amount of pain medication

used after surgery. Previous research that has evaluated health status has been with

individuals who were in "poor health" with long-term disability after surgery.

Most participants considered themselves to be highly spiritual and used spiritual

coping methods such as hoping, praying and dependence on a higher power. There is no

previous research that has examined the spirituality and postoperative pain or pain

medication use afterjoint replacement surgery. Previous research that evaluated

spirituality, health assessment and functional recovery used a very different patient

population. The only similarity was a high degree of spirituality among the older adult

rehabilitation patients (Fitchett, et al. 1999; Kim, et al. 2000; Pressman, et al. 1990). In

my research, most reported that they used spiritual coping methods and behaviors such as

participation in spiritual activities, spiritual writings and prayer. They also believe their

spiritual health contributes to their physical health. The majority of the participants in

this research used these spiritual coping methods. However, there was no evidence that

high self-evaluation for spirituality influenced pain or pain medication use after total joint

replacement surgery.

Strengths and Limitations

Although this research had strengths, it was limited in its methodology. Primarily

it was a convenience sample of pre-operative total joint arthroscopy patients. This

research was impaired by the use of regional anesthesia by the majority of the

participants. These patients received more regional anesthesia techniques for pain control

postoperatively than most other surgical patients. Regional analgesia is an effective

technique in the treatment of post-operative arthroplasty pain. Pain report and









medication use for this group of patients were affected by the use of the regional

anesthesia techniques. It was not possible to control for the increase in regional analgesia

techniques during this investigation.

There was an uneven distribution of males and females. This was to be expected,

but did not approach the 2:1 ratio for osteoarthritis found in previous research. There was

no ethnic diversity found in this research and this finding does not represent the ethnic

distribution in the geographic region.

Implications for Nursing Practice and Future Study

There is evidence from this study that these patients requiring total joint

replacement for osteoarthritis have a high degree of spirituality and perceive their health

as good to excellent. They use spiritual coping and behaviors such as prayer, spiritual

activities, and belief that spiritual health influences physical health.

Second, they feel their health is good to excellent regardless of their functional

limitations or pain. This self-assessment of good health contributed to less pain after total

joint surgery, but did not lessen the need for pain medication.

It is important that the clinician recognize that the postoperative patient is

multidimensional in their self-health and their spirituality. This quantitative study did not

support the hypothesis that spirituality decreases pain or pain medication use. This

research did find a relationship between self-assessed good health and decreased pain, but

did not find a relationship in less pain medicine use. This research contributes to the body

of literature evaluating spirituality and health in the older adult.

Future research should include postoperative function and pain using longitudinal

data collection. Assessing joint arthroplasty subjects pre-operatively, one month

postoperatively and at the end of the one-year recovery period would provide long-term









data on the relationships between spirituality, self-health assessment, pain and physical

function. Correlating functional longitudinal data with spirituality and health assessment

would provide more pertinent information without interference from postoperative

regional analgesia.

The implications of this study for nursing practice are that the findings of this study

support the use of spirituality and spiritual behaviors by the majority of the participants.

Good to excellent self-health assessment did change the amount of pain these participants

reported after surgery. Nurses should be more at ease in assessing a patient's spirituality

and self-health. Nurses do have to recognize that how a patient evaluates self-health may

be important in reducing postoperative joint arthroplasty pain.

In summary, evaluating the participants' spirituality and self-health assessment

found interesting relationships between postoperative pain and analgesic medication use.

Second, these research findings have implications for further future nursing research.















APPENDIX A
LETTER OF AGREEMENT
















1 UNIVERSITY OF
FLORIDA


,tlcr.- oni Mdedrp,.
eputment of Drthopedics and Rehabilitation



July 25. 2003


R. Petr lafate, PharmiD.
Chairman IRB 01
Box 100173


PO Box 100246
ainewsil FL 326~04)24
Plr.e i3t1392-L51
Fa.. 352i 3r2-afb37


Re: Poject 259-2003 "EBfecs of Spiral Belies and Involvement and a Positive Self-Halth
sicssmnenl Lri PredLr;n POSt-Operati Analgesic Medicaion Use in Total oint
Arhroplasly in the Older Adult"

Dear Peter,

I am aware of Pau riia McNaily',s audy on Lh, eAliecu of spiriiWIa bdicfs and its relationship on
pr1-opje)[alc analgcic imTdicadtir in lotl joint arthroplasty. She and I have had multiple
convenwrsaions about the study and the implementation of iL


1 appreciate the work and diligence of your group

All rhc hWi,

Sincerely.



Peter F. Gemren, M.D.
Associate I'roi'es~r and I[ntim Chairman
Dcpnirmnci ofOrhopaedics an] Rtehailliison

PFG/M

CC: Ms. LLrLId Kephan FI iln
Coordinmolr Rie~arUh Programs
Box 100173















APPENDIX B
INFORMED CONSENT 08-19-03 TO 07-15-04















Infonneconstl 0 Pakw re har kan k Sr
ond .whOraauetonfor Collecrion; Use, and
Disclosure of Protecled Heallh 14(onnfaton


University at fiorna
Heath Center
Instllional Review Board
APPROVED FOR USE
fea~8i9.m ffjt~fo -i~agi


IRB# 2S92003


You r being asked to take par in a research slid. This form provides you with Infomlion
about ite srud and sleks your auhonzation for the collkln, use and disclosure of your
proclead hcaltlih fomnnion necessay forthe study. Te Principal invewigaior (le pcrsn in
carge ofthis research) or a representatiw" offh Principal Investiglor v-il adLo dscnibe Ihis nsudy
to you tn ansHer aLi of your questions. BcfoI)ou decide whether or noi to tke pan, read ihe
information below and ask quesiorm about anything you do not undcstm d. Your participation is
entirely voluntary.

1. Nime or P lartpnpal ("Sludy Subject")



2. Tilk of Rearch Study

Effects ofSpiritual Befeis and rnvolvenwy t end a Positive Self-Healh As5csmer t in
Predicing Posoperative Analgesic Medication Use in Total Jont Athroplasty n the Older
Aduh

3. Principal lanvestgar and Tclkphone Numberis)

Patricia Anne McNalt
352-281-7452


4. Somrce orFundlag or Other Material Spport

University of Firida


S. What l the purpose of thi research study?

You are being asked if you are itereed in parric~patiinn his tidy because )ou are


259-2003 07-10-03 / Page 1 of 7












scheduled fr joint repllacinent surgery. This study is being done to ser if thre is a
relationship between your spiritual belef h and your health evaluation and your nted fr pain
medicine. T11 purpose o ihis study is to measure the amount of ain medication you use for .
the first three days after )our surgery.

6. What wWl be done if ou take part l (hias research study?

You will be asked to participate in this sIudy after >ou haFe been scheduled with Dr. P.
Gearen for hip or knee replacenmnI surgery. Through your panicipalon -i this study you will
be asked to complex Iwo survey questionnaires. These survey queslionrA~res ul l dke
approxin~tely 20 minutes io complete. You do not lave to answer ahl ofth questions if you
do not want to answer lL The purp~bc orthis study is to explore reltionshps between
sprtual beliefs, spiritual involvcneni, a personal health evaluation and the amount of pain
indication use after joint replaemen surgery. Your medical record wil be eaminied for
three days after surgery to determine the amount orpain ou report nr surgery and the
amount of pain meication you use. Other info nm oron e'mincd froim your medical record
Aill include your age, sex, diagnosis, location orjorum replacerncni and anesthesia given 10
you during your surgery. The Prncrpal Investigalor will code Oil ofyour infor nnion wilh
confidential code numbers. All ofyour data will kep in a locked secure fie.
All of your care wa be normal procedures ihat arc part of he ireaL-erm for all patients
haT-irng otial joint replacernent surgery. There will be no differences in your treatment while
you are part ofthis study.


7. Whma ar e heposible discomforts and riss?

There will be no possible risks for you as a participant in this study. You may experience
discnmfort in aswering qulestons regarding .3ou spirilualil)
Throughoi the study, the researcher will norify yu of new infomaliaon that nay become
available that irna) aff et .or dJcsion 10 reniain in the sudy.

If you wish to discuss the information above or anr discomforts you nmay e, ask queiorns nrow or call ihe Principal Inlrigator or co cun person listed on the front page of
this form.


sa, What are the possible baenelts to you?

There are no benefits to you as part of hi study.


8b.What are the possible benefits to others?

If this lsudy should show a relationship between spiritual b]ie l spiritual participation
person health evaluation and pain medication use, other studies may be done to develop
alternaiWve ways to treat patients in the future.


-;9.-03 / 07-10-03/ Page 2 of 7













9. If you oose to take part in this retarch study, will It ct you anything?

Thre wig be no change to you for being part of this study.


10. Willyou receive tompenIallin for asking prt in this reserch study?

You will not be paid for taking par in ths study.


11. What If you are Injured because of Ihbe b hl.?

[rfou cip.cricen an injury that is dircy caused by this slidy. only professional consulllive
care thai you receive at the University of Florida Health Science Center will be provided
without charge. However, bespiial cxpensi will have to be paid by you or .!Fw i,-ksurancw
provider. No other compensation is offered.


12. What olher options or treatments are atailjble if yu do not want lo be in this sudy?

You ar free 10 choose no to take pa in this study. Ifyou chose not to take part n this
study. your joint replacement surgery will continue and you wil receive the same level of
care. f you do not want to take part in this study, tell the Principal Investigaor or her
assistant and do not sign is Ii nforned Conseni Form.


13a. Can you wilhdraw from this reuear study?

You am free to willdraw your consent and to slop partkipalr' in his research study at any
time. If you do withdraw your consent, there w~II be no prally, and you will not lose any
benefits you are nlitled to.

f you decide to withdraw your consent to panricpaie -i il research sudy for any rJson, you
should contact Patricia Anne icNalty n (3 5 ) 2!1-7452.

Ifyou Iha e any questions regarding iour right s a rescich submi. you may phone the
Institutional Review Boad (IRD) oflte at (352) 846-1494.


13b. If you witlhdrw, can inlormatloa about you still be used sad/or collected?

f you withdraw fronm the study. the principal inveslator would like to mrninue io keep end
use bhe infonnation that you conpleed using the questionnairs, pain scores, pain medicine
and other information obtaied from your medical record If ou refuse to le the Principal
Invesigator continue to keep and use this information, it will not be used.


259-2003 07-0-D3 Page 3 of 7













13c. Can Ihe Principal investigator nihdraw you from hbis research stud)?

You may be withdrawn firn the sLudy without your consent for the following reasons;
You did not quality to be in ait study because you do not meet the Sudy reqLirimnnts Ask
the PiLnipal Investijiiorr if you woltd like more information obos this.


14. How nlIyour privacy and the confidentitUl) of hour prorreld health informarion be
protected?

Data will be gearered and maintained using confidential codes io proltiu o'Lur identify. Patricia
McNally, the Principal Invstigator, will gather medical data obtained from your medical
cord. All data and inirmtion will be kept in a locked file in the office of Palrlci McNally,
the Principal Invcsigalor. Patricia McNally wi a.sgn aU confidenLal code numbers Access
to your file w be restricted to the principle investigator.

li)ou participale in ths research, your proiccied h dilh infonrm ion will be coUlcc.-d used, and
disclosed under the terms specified in seclio 15 23 b-low.


15, ItIou agree to pardcipate in Ibis rtwarch arudy, what prtected health nforl action
about you may be colleci d, used d disclosed to other?

To dvlennine your cligibly rb r Ihe study and as part of your participation in the study, your
protected health Infornn;ton that is obtained from you, from review cf your pst. curmiil or
Ifture health record~ from procedures such as physical examntions, xrys, blood or urine
tests or other procedures. forn your response to any study trealnm ts you receive, from your
study visit and phone calls and "a other sludy relitd hrthh inlbrmntion, may be collected,
used and disclosed to others. More specifically, the fllowig information may be collected,
used, and disclosed to others:
Complete past medical history to determine rig iihi y criteria listed in informed consent
Quest ;onnires that you have comptl8ed
Medical records about yourjoinl replacement surgery
Medical records about pain nmdiialion us after surgery
Medical records about pain reported
Mkedial reords about ancsiF ia used during surgery


16, For whal srudl-relled purposes sill )our p roecled health lnformati a he coll0Eed, used
and dbclosed to others?

'atrr protlcid health information may be collected, used and disclosed to others to find out
your eligibility for, to carry out, and to !e auaic the results of the research study. More
specifically. your proectred heJath information may be colkleted, used and disclosed or the
Iblloling sthudy-reiued purpose): to determine if our slf-hrclsh assesrineri and spiritual
beliefs and spiritual parlicpalLori are related I. your pain afler surgery.


2 9- 2uU1 /07-10-03 F Pae 4 of 7














17. Who will be authorized to collect, use and disclose to otfbrs your protected health
iiformalion?

Your prolecled health r-formation may be collected, used, and disclosed to others by

the study Principal Investigator. Patricia A. McNalty
Dr. Peer Gearan, ChairnmuL Depanmenl of Onhopedii Shands at UF
ohir professionals oa the University of Florida or Shands Hospital thai provide study-
related ratment or procedures
The Univesity of Forida Institutional Review Boad



I1 Once collected or used, who may your projected health information be disclou-d lo?


SUS and foreign goviermenual aSencs who are responsible for overseeing reach,
such as the Food ad Drug Adrmnistration. the Department of Heakh and Human
Services, and the Oilice ojF Huan Research Prolcclbons
Government agencies who are responsible for overseeing public health cones such
as the Centers for Disease Cotrol and Federal, State ad local health departments


19. Ifyou agree to partlcipale ln bis research, bow lo will your protected health
information be collected, used and disclmed?

Your projected heallh inbrnmaion will be used and disclosed forever.



20. Why are you being lasdt roe turhorhz Ihe collection, use mad disclosure to orher afyour
protected health inornmalion?

Under a new Federal Law, researches cannot collect, u.e or djsclor any ofyoa prolclicd
heacih [nifmu ion for research unless you allow them to by signing this canse arJ
authorizarion.

21. Are you required to sign this content and authorizatin and allw the researchen to
collect, use and discose (give) to others ofyour protected health information?

No. and voLr reiual ro sign wilm nt alffcl yor Ircalnmeni, payment, oero1Mb nl, or eliibilty
for any benefits outside this research study. fHoiver, you cannot participate In tis research
unless you allow rhe collection, use ard dtscairir'e iftyrir protected he lth mrobrowaion bi
signing shis cwfasendmfrkorlaftio


259-2003 / 07-10-03 / Page 5 of 7













22. Can you review or copy your protected health infomatioR collNcted, used or disclosed
under iis aulboratlion?

You hanw the righ to review and copy your projected health infonnrion Howvr, you will
not be allowed to do so until after the study is finished.


23. is there a risk tht your prorwled health Ina rma ion could be given to others beyond
your authDrinzlioB?

Yes. There is a nmk Lhat injornuiCOn received by owlhorized psernS couDJ be given to others
beyond your aufthrizalion and rit covered by the law.


24. Can you revoke (cancel) your nuthortbtion for colectiona use and disclosure ofyour
protected health Information?

Yes. You fcn ca-.el your aLuLhrizaion a1 iny time before, during or aflnr you pnnicipaiion in
the rcscuch. Ifyou cancl, n nnew inform ationr wil be collected about you. However,
infornation tht wnas ready collected may be sVM be used and disclosed to others if the
researchers have crlied on it to complete and project the vraLidny ofrie research You can
cancel by giving a wrInLn reqicsi whih 3our signature n hi to the l'rinipal lnuesiigioor


25. How t ll rhe researchers) benefit from your being In this study?

In gcr erdi. prcscninfl research results helps carmLr uo scientli Tlhrcrore, ihe Principal
invesialor may beneEf if lhe result orfhis trudy are prCesnted t siehulrIC nrcing or in
scientific; journals.


259-2003 / 07-10-03 / Page 6 of 7







61




26. Signatures

As a representative of this study, I hav explained to the participant th purposL4 the
procedures, the possie benets, and ihe risks of his search study; the alternatives to being
in ihe study, and how the pnrticipdan's proicled hr lrh inrormnilon wil be collected used and
disclosed:




Signacl of Person Obnining Consern and Authcriarmon Date



You have been informed about thi study's purpose, pocedres, possible benefits, and risks;
the alternatives to beirg n he study. and how your protected hcnhh infomnlion wifl be
covected. used and disclosed. You hImc recc. cd a copy of his Form. You have been given
the opportunity to ask quer ians before you sign, and you have been told that you cn ask other
questions at any tmne.

You olunrilyarn agree co parikipate in this sudy You herchy aulhorize he colBection, use and
Lisclosure ofyaur proiecied thelrh unformalian us d-cribcd ir setIonm. 14-24 above, By
signing this f you are not tiiving any of your legal rngrh;




Signature ofPerson Consening and Aulhorizing Date


259-2003 07-10.03 / Page 7 of7















APPENDIX C
INFORMED CONSENT 01-29-04 TO 07-15-04














Informed Conset to Paricipae in Research
and Autkhorriaon for Collecion, Use, and
Dicrlosure of Protected Health Itnformamion


IRBiB# 259-2


University of lorida
Health Center
Inslitutional Review Board
APPROVED FOR USE
From I J/ o./ Through 7, /^/0


Yolu ar being asked to take pIt in a research study. This form provides you with information
about die study and sees your aulhorizalion for the collection, us and dis lI run:r L your
proteclcd health information necessary for the study. The Principal l i ics;I lc.r ( Lh person in
charge of this research) era representat ivofthe Principal Lrivemigaior will nlio Jdcs:nbe thi- ijuly
to you end answer all ofyour questions. Before you decide whether or not to lake par, read the
inmfonaionn below and ask cqucstrion abCtui an.U lliring )jo dJo njiot understand. Your particIpaliaLo L
entirely voluntary.


L. Name or Pn.ariipint ("Study Subject")




2. TIle of Resenrch Study

Effects ofSpiritual Beliefs and Involvement and a Posiltve Self-HelLh Assessment in
Prdliclng Postoperative Analgesic Medication Use in Total Joint Arhroplasty in Ihc Older
Adult


3. Principal Tn% esaiglor and Telephone Number(s)

Patricia Anne Mc N.ll)
352-281-7452


4. Source of Funding or Other Material Support

University of Florida


259-120031 Rv Ol7.27-04/ ~ge 1 of 7







64





5. Whal is the purpose of this research study?

You are being asked if you are inicrcscdj in p.aicip.liing in this study because you are
scheduled forjoin replacement ,urer Tins srudy i b ing do~ to scc if there is a
rcliaionship bctwcn your spiritual beliefs ain your: ellc evaluation and your need for pain
medicine. Tie purpose ofthis sludy is to measure the amount oCpain medication you use for
the first tree days Ailr your surgery.


6. What will be done if you take par in this research study?

You will be asked to puriAipaic in Ihs study allcr you have been scheduled with Dr. Gc;rc~i.
Dr. Myers, or Dr. Vlasak for hip or kne replaccaernt surgery. Through your participation in
ihis study you will be asked to complcle two survey questionnaires. These survey
qliisl;onnoircs will Inta uipron\ila[cI 20 minutes to complex,. You do not have to answer
all of the questions if you do not wanl I ans.cr all The purpose oflthis sludy is Io explore
reltioinships between spiritual dclicf1, spirilital involvement, a personal hall evaluation
and the amount of pain nudicariin use aRlr joinil rcplacmoncl surgery. Your medical record
will be cxainned for three days after surgery to determine the amount of pain you report after
surgery and the amount of pain medication you use. Other information examined from your
medical record will include your age. sex, diagnosis, location ofjoint eplaoen nl atnd
ansllhesia given to you during yo surgery. ThS Principal Invcstigator will code all of yrur
information wilh confidential code numbers. All ofyour daa will kepl in a locked secure
file.

All o your care will be normal procedures that re part of thc treatment for all patients
having, lotal joint replacement surgery. There will be n iliu n uiiccrin your Irealmcnl while
you ire part IrFlh; s.1mily


7. What are the possible discomforts and risks?

Ilcre w ill be no po:sibli ri.l,. for you as a pw;ric;pinl in ihis study. You nmayexperince
discomfort in answering qiuJerionr rc~grdi;ng your spiritualiy.

Throughout the study, the rzcserclier %..i]l IdcIul'y yu of ew informaltion that may bcornue
available that may ufacct your decision to remain in the study.

iryou wish to discuss Ihe information above or any discomforts you may experience, you may
ask questions now or call he Principal [nvesigatror contact person listed on the front page of
this form.


8a. What are the pouiblre lirnerli tn ou?

There are no bencils to you as part ofthis study.


259-2003D Rev 01,27-04 /pTa ",c- 'i













8b. What are the possible benefits to others?

[ this study should show a rclaionship between spiritual beliefs, tpiri mal p.ir;icipaiion,
personal health evaluation and pain medication use, oLther sudies nay I e incrin 1i develop
allcrnalive ways to treat patients in Ihe future.


9. ir you choose to take part In this riearch urud., will it cost omu anything?

There will be no charge to you For being part of Ihs study.


10. Will you receive compensallon for taking part in this research study?

You will not be paid for taking part in this study.


i What if you are injured because of the study?

If you experience n injury ih,[ is dircvcly caisid by thLs iuJy. oily prlf5ssioal consullative
care Ihat you receive at the University of Florida Healit Science Center will be provided
without charge. However, hospital expenses will have to be paid by you or your insurance
provider No ontiir coripcnniicin is offierd


IL2 What olhrr option or trrat m(a rire a c ailahcl if you do not want lo be In Lhis stud)?

You are Free to choose not to take part in [his study. If you chose not to take part in this
study, yourjoint replacement surgery will continue and you will receive the same level of
care If you do not want to take part in LhI i ~udy. tell the Principal Invcsligalor or her
assistant and do not sign this Informed Consent Formi


13n. Can you wlllhdraw from this research olud) .

You are fre to withdraw your consent and to slap panicip ling in this search study at any
rime. If ou Jo 'viilhdr o )or con.wnr. there will be no penally, and you will nol lose any
benefits you are entitled to.

II you dec, ide no wulniri-w your consent to participate in this research study for any reason, you
should contact Patricia Arne McNally at *3'52, 21 -7452.

If you have any questions regarling your righ as a research subject, you nay phone the
Institutional Rc-lew Ejrd (iRBi oicc F l (.1521 46-.194.-


13b. If you withdraw, can Information about you still be used and/or collected?

If you withdraw from the study, the Principal Investigator would like lo continue to keep and


2 9-2003 t/ r 0v L-214 / Page 3 or7













use the information ih.at yoi corr1pFl)cd using ihe qluisiornaires, pain scores, pain medicine -
and oilier information oblained from your medical record. If you refuse to let ihe Principal
Invesligalor continue to keep and use this inirmialion, it will not be used.


13e. Can the Principal In cstnigitor withdraw you from this research srudy?

You may be u ihdrain from the study without your consent for the following reasons:

SYou did not qualify to be in dIe study because you do not meet the study
requirements. Ask the Principal Invesligaor i you would like more infonnmaion
about this.


14. How will your privacy and the confdenlela.lly of your prrretrld health infnrmalWnh be
prot ictd?

Data will be gathered and maintained using confidential codes to protect your identity. Patricia
McNally. the Principal Ir' scligpor. will gather medical data obtained from your medical
record. All dala and information will be kepl in a locked rile in the police ofPaTui ciE McNlly,
I|Lu Pnricipal [vestigator, Patiicia TlMcNall dill assign all confidential code numbers. Access
to your Fle will be restricted Io ihe Principal Investigator,

if you participate in this research, your protected health information will he co lkl.-d. used, and
disclosed under the te=s specified in secions 15 24 below.


15. If you agree o participate in Ib s research slud). bhat proiLert-d hea lh idfornArian
about you may be coUeted, used and disclosed to others?

To dLirreir Lc ui c! igibili Ly if the sIudy and as paIr oI your participation in the study, your
prolected heallh infrmnalion that is obtained from you, fro review of your past, cuarcn or
future health rcconls, from procedures such as physical examinalions, x--nys, blood or urine
less or other procedures, rom your response to any study treatments you receive, from your
study visits and phone calls, and any oLliier asudy rriar-d IL akh information, maybe collected,
used and disclosed to others. More specifically, tie following in frunritiion ma y bK collecled,
used, and disclosed to others:

Complete past medicaL history to dalerninc eligibility criteria listed in informed
consent
Questioniaires that you have completed
SIMcdical rc-rd 1 aboful yourjoint replacement surgery
SMedical records about pain niedcalion use after surgery
SMedical records about pain reporlcd
Medical records about anesthesia used during surgery


259-2003 / RcV 01-21-.4 I'Pac 4 of 7







67





16. For what slud%-relaied purposes will your proteclod health information hb IclleclCd, used .
and disclosed to olbers?

Your protected health inrfomation may be collccled, used and disclosed to others to lind out
)ouc cligibilily for, lo carry o' aani is ievalu.ai1,Is il-resuh of [he rec sarn study. More
S .' Fticall. your prOLcMLCd health informJltioi nmay bccciL cct used and disclosed fo r he
following study-relaed purpose(s):

Sto dclcrminc '1 your selF-illalll i rsncmrnt and spinliual bliefs ad rpJ ninal
participation arc related to your pain after surgery.


17. Who wll be authllorized o collect, use and distrlse to others orur protected benlll.
information?

Your projected health inrbormnion may be collected, used, and disclosed Io otherC by:

Ihe sluJy Principal Investigalor. Patricia A. McNally
SDr. Per Gearen, Chainnan, Department of Orthopedics Shnds :i UF
oljer pro fisionals ai Ihe Uniln rsily of Fori da or Shands Hospital tha! proi; siuJv-
related irealmeni or pmledures
The University of Florida Instilutional Review Board


I. Once collected or used, wiso may your proie~tcd health information be disclosed le?

Your proteled health information may be given to:

United States and foreign oriimniernal 3agenc js -.FW iac responsible for overseeing
research, such as the Food and Drug Administralion. lhe D'p rrFmnrlt ofEcallh and
Human Services, and the Olfice ofrHuman Research Protections
Government agencies who are responsible for oVers~r ing public hc aih conc rrn i ch ~s
the Centers for Disease Control and Federal, Stale and local health departments


19. If you ngree to pnrliclpate in Ibis research, how long will your proteetrd health
information be colleled, used and disclosed?

Your protected health information will he colleled until the end of ihe srudy, This
information will be used and disclosed forever sine it will be stored for an indeinile period
of time in a secure dainbas.


259-20031Revo01,27-04: l'iL,c ?













20. Why are you being asked to authorize the colleclion, use and disclosure to oihrs ofyour _
protected health information? -- .

Inder a new Federal Law, tesearhecs cannot collect, use or disclose ry oar~iour priorlece
heallll inflorr'ion for research unless you allow them to by signing Ihis crnsnt and
authorization.


21, Are you required to sign this consent and authorlzallon and allow the researchers to
colIect, use and disclose (gisc) lo others of jour proiecled health information?

No, and your refusal to sign will nol afei'i your treatcnt, payment, cirollnrenti, Lreligibiilty
for any benlils outside tUis research study. However, you carJemo puirtr epa e in ld rfearclh
less you allow ite colleactri, ufenr orVl lisclosure of iiur prit;ectelhearih information by
sigdng this consentauthoriztion.


22. Can you review or copy your protected health Informalion collected, used or disclosed
under Ibis authorization?

You have the righi to review and copy your protected health infonntmion. Htlow. e. you will
not be allowed to do so unlil after ihe study is finished.


23. Is there a risl that your protected hbeth information could be given to others beyond
your authorizatlonu'

Yes. There isa risk that information received b) -unihori/ed persons could be given to others
beyond your authorization and not covered by i e law.


24. Can you rn uke (cancel) our aulbnorization for Ltoltion. useand dlsclosureor your
proleeied hralih information?

Yes. You .cincancel your auiuhoriil'(rt at any time before, during or oafer your participalion in
rie research. Ifyou cancel, no new information will be colJecied ambui you. However,
information Ila iass already collet rd im..y be slll be used and disclosed to oth s ifthe
researchers have relied on it wo currpleie and pruicci tihe ;dciill of ite rLse3arch You can
cancel bygiving a "vnhin rcquei u IC )t your sipnalurc on it to Ihe IPnrnip:I hIliiigator.


25. How will lte rsen reheril-s benefit from your bring in this study?

In general, presenting research results helps the career or a scienlis. Therefore, the Prinipal
]i ts Lnig. t. ma~ bcnefi if the results oflhis study are presented at scientific meetings or in
scientific joumnts.


259-2003 / Rev 01.27.41 ligc of 7













26. Signatures

As a representative of Uis study, I hIve explained to the participant the pLurpse, the
procedures, Ihe possible bir fisL. and Ihe risks of this research study; Ihi alternatives to being
ini the 51udy. and how the participant's protected health infoTmaton will be collected, usel, and
disclosed:




Si griauur of Peron ObLt ning CoInsIe ani Aulhon-alon Dale



You have been informed about this study'spurposc procedures. poaible benefit, anr nskst.
theallcnalivcs [o being in Lh2 sNudy. and howv your potected health information will be
collocietd. used and disclosed. You have received a copy of this Fonm You have been given
lthe opportunity lo ask questions bclirc you sign. and you have been told that you can ask other
questions ai any line.

'ou volunU~rily agree to palicipalt in this study. You hrreb" .uuLhori.h the .lkction, use and
disclosure oryour prolecled health information as described in sections 15-24 above. By
signing this ronrm you are not waiving any o your legal rights.


Signature ofPcrson Consenting and Aullhorizing


Dale


25900W IRcrv o1-27-04 / Pag 7 of 7















APPENDIX D
INFORMED CONSENT 07-16-04 TO 07-15-05















hIfon irm Consent to Paniidpnte in Research
and Authofriation for ColteeioMn, r, an d
Disclosure ofPrateced Health lifororaton


University of Florida
Health Center
lnstltutional Redew Board
APPROVED FOR USE
_Fr -4om__ Through V14.47.r
cS4


IR# 259-2003


You are being asked to lake part in a rsarcmh study. This form provides you wi h inlbrri lion
about ie study and seeks tour auithorin.aion for the collection usc nd disclosure aof yu
proecrid hea in irlbfor-minion nccLssarl for Ihe sludy. The Principal Inc si~aigor (die peron in
ichw;a oflhis rcA&erch) or a rcprcrsnlaiie of lIhe Principal Investigalor will also describe Ihis sludy
lo )ou arid jiriswLTr all ofyour questions. Your pilricipallr n is entirely voluntary. Before you
decide wlielher or not to take pan. ri.jl he iniomrrniaLn below irid ad. quiesiiont abcul ma)hin
you do nol understand. 1i you choose notr 1 participate in II~s s5Idy )ou will not be peniialcd or
laic lrny baiclils thai you woUld thterwAise be eirirEllnj l.

1. Nameof Participint ("Study Subject")




2. T'ileof RfslarchSludy

Eff is of Spiri;ual Beliefs and Involvement and a Positilc Seir-l lealdi A.-l5sin-iFci in
Prrdiciing Postoperative Analgesic Medicaion Use in Tolal Joint Artiroplasty in Ihe Older
Adult


3. Princpnl InTieslgalor and Telcphoae NunmbP~is)

Pairicia Anne McNally
352-281-7452


4. Source of Funding or Other Mncerril Support

University orFlorida


259-2003/Rev 6 4.4 /P Fc I of 7














5, Whal is the purpose of this research study!

You .ce being asked if you are interested in participating in this study because you are
scheduled for joint replacement surgery. This study is being done to sea if there is a
relationship belween yoLir spiri ual beliefs and your health evaluation and your need for pain
medicine, "Te pu-jpos of ih atludy is to measure the amount of pain inediehiiOn you use for
the frsi three dayi after your surgery,


6. Whnt will be done If you take part In this research sludy?

You will be asked to participate in this sludy after you have been scheduled wilh Dr. Gearen.
Dr. Myers, or Dr, Vlasak for hip or knee replacement surgery. Through your participation in
this study you will be asked to conrpile Iwo sure queslionnaires. These survey
questionnaires will take approximately 20 minutes to comptele. You do not have o answer
all of the questions if you do not want lo answer all. The purpose of this study is ln cmprincE
relationships between spiritual beliefs, spiritual involvement, a personal health evaluation
and the amount oflpaiin irdicalaion use after join replicirnini surgery. Your medical record
will be examined fcr there days ailer surgery to determine the amount of pain you report after
surgery and the amount ofpain medication you use. Oitlr inormiaiion etrnirncd from your
niedical record will includuc iour age, sex, dl.gnosis. loCAlIon ol'joint replacement and
anesthesia given to you during your surgery. The Principal Invesligalor will code all of your
informnlion wiih confidential code numbers, All orfyour data will kept in a locked secure
file.

All of your care will be normal procedures that are part of the ircatment for all patients
having tolal joint replacement surgery. ThLre Iill be no diTerences in your treatment white
you are part of this study.


7. What nre she possible discomforts and risks.

'Thee % il1 be no poNssibl nsks for yci as a pa ticiprnl in this study. You may experience
discomfort in answering queinions regardriin, our spintiulal').

Thrlouia1uii ihc sirdy. the researcher will nolify you of new information Ihait rmy become
available that may affect your decision to remain in the study.

If you wish to discuss the information above or any disconforts you may experience, you may
ask questions now or call the Principal Investigalor or contact person listed on the front page of
this form.


SaB What are the possible benefits to you?

There are no benefils Io you as par of Lhis study.


259-2003 / Rv 06-144 / Page 2 of 7







73





81. What are the possible benefits to others?

If Ihis iudry should show a relationship between spiritual beliefs, spiritual paiicip.Ilion.
personal hcallh evaluation and pain medication use, olher studies may be done to develop
allemative ways to Ircat patients in the future.


9. If you choose to take part in this research itud will it cost you anything?

There will be no charge to you for being part ofthis sludy.


10. WIl you receive compensation for taking part in this research study?

You will not be paid irr Ik in g part in this study.


11. What [fyou are Injured because or the studio ?

IFyou experience an injury that is directly caused by thii& study, only prifie.'iunal consultative
care that you res; c iiL the Uri crsily ofFlorida Health Science Center will be provide
.-irhoul chirgc. I Ich. o .-r. hospiinl expenses will have I be paid by you or your insurance
provider. No olh-r compeisilion is oflTfr Please contact the Principal Investialor listed in
Item 3 of this fImOi I yoLL \pc ricnce an injury or have any questions about any discomforts
that you experience while participating in this study.


12. What other oplioni or Irenrments nre aiallable If you do not want to be in ihis ludy?

You are free to choose not to take pan in this study. If you chose not to take part in this
study, yourjoiint replacceninc surgIery will continue mad you will receive Uth suam level of
are. if you do no want to take part in this study, tell the Principal Investigato or her
assistant and do not sign this Informed Consent Form.


3an. Can you nwitdraw from this research study?

You ar free to withdraw your consent and to stop participating in Lhis research sludy at any
time. if you do v6ilJhdiraw our conscri, there will be no penalty. and you will not lose any
benefits you are entitled to.

If you decide to widldraw your consent to participate in this eearh study fbr any reason, you
should contact Patricia Anne McNally at (352)28 1-7452.

If you hav an) q actions regarding your rihl as a research subject you may phone the
Instilulional Review Board (RB) office al 1352p 846-1 49-4.


259.2M00 3 Rev 06-1-041 Page 3 of 7














13b. If you "%ilhdran. can information about you still he used undinr collected?

If you withdraw from tie study, the Principnl Investigulor would like to continue to keep and
use the information ilat you complete using Ihe questionnaires, pain scores, pain medicine
and olher infornaiion obtained from sour iili~al record. If you refuse to let the Principal
Irn ctigsator corlinuc to keep and use this inf rmniiori, it will not be used.


13e. Can the Principal Investigator withdraw you from this research study?

You may be withdrawn from hde sludy without your consent for the following reasons:

You did not qu.ilif) Ho 'c- in the study because you do not meet the study
requireonentis Ask the Principal Investigator if you would like more infbormalion
about (his.


14. How will your privacy and the conflidencialir of )our prolected health informnaila be
protcoed?

D)la will be 4i.hcl.iLd a-ld nriinlaincJd using conldential codes to protect your identity. Patricia
McNally, the Pnicipal Investigator, will gather medical daa obtained from your medical
record. All data and infonnalion ill bI kept ni a lxked ile in WUiL ofITe:c of Patricia McNally,
the Principal nvcstigator. Patricia McNally will assign all confidential code rnwbers. Access
to your file will be restricled to the Principal Investigator.

If you participate in tlis research, your projected health information will be collected, used, and
disclosed under the iiens specified in sections 15- 24 below.


15. Ifyou agree to parllcipale in hiis research siudy. what protected health information
nhout you may be collected, used and disclosed to others?

To determine your eligibility for die study and as part of our panicipr lion n the study, your
protected health ifornalion tant is obtained from you, from review of your past, cu ren or
JurLUic hc iJLh rccords, from procedures such as pl.) i-c examinations, x-rays, blood or urine
tesis or other procedures, from your response to any study trealmenis you receive, from your
study hisii5 and phone calls. nnd aniy other slud) relat-d hcalih ini m.ilcior. rniy be collected,
used and disclosed to others More spec icnll., the following infonnalion may be collected
used, and disclosed to others:

Complete past medical history a delerin eligiili c rcrineia lisrd in informed
consent
SQuestionnaires thai you have comptcled
SMedical records about yourjoint replacement surgery
Medical records about pain medication use after surgery
Medical records aboul pain reported
Medical records about anesthesia used during surgery


-259*003 I ev 06Rc 4.- Pa 4 of7
















16. For wbat sludy-related purposes %ill your prolecLed hnlllh in ormation be collected, used
and discloIed to others?

Your proTecile hcj.ih i nforiaiori may be collected, used and disclosed l otlirs to ind oul
)our c I ig]hil] I f'Tr. to carry ou, and to evaluate the results oflhc research study. More
spiT.ilkla ly. your prlolcted health inlrcmiarion maybe collected, used and disclosed for te
Iollo.ing nudy-r.laiqd purpoae(s)

to dlcrrnie i'your s-lf-halil]i ;ssisn l enr and spntual beliefs and spiritual
pan;cip.j ion are rcialed to your pain after surgery,


17, Who will be auirlorlzed to sijlitcl. use and diclos lto others your protected health
Information?

Youw prolecced Ilealll infoermition maybe collecied, used, and disc.ors d to others by:

tlic sudy Principal invesigator. Patricia A MciNaJl
Dr. Peter Cearen, Chairman, Department or'Onhopediii. Sliar s at UF
oihcr professorilsl at rhe Univerity of Flonda arSh~nds Ho1lsilhi hal prio' mlC saidy-
rclated treatment or procedures
Th University of Forida Instituional Review Board


18. Once rollectrd or used, who may your protected health information be disclosed to?

Your protlcled health information may be given to:

SUniled Slates and foreign governmental agencies who are responsible for ovrseeing
tresarh. such as the Food iirsi Drug Adminiriinior.u Ihe Department of leallh and
Human Services, and the OiTicc of Hinan Research Proteclions
9 Govemment agencies who are responsible for ovcrsceiri public Iheith conccns such la
the cntlers for Disease Control and Federal, Stame uid ]ccal healIh depatnients


19. If you or9et to pnrlicipale In this rcsnerch, how long will your protected hellth
information be collcilcd, used nnd dlL.closed?

Your protected health infoamaion will be collected until the end oflhe study This
information will be used and disclosed forever since it will be scored for an indefinte period
of time in a secure database.


259-S03 I Revy0&1.4W I/Pftt ~ of 7














20. Why are you being asked to aultoriz the collccrion, use and dicTrourt ro oiheri uf your
projected health information?

Under j nc". FodcraJ Law, rrcfrcher crulrnnr ol [Ml. s or disclose any oryour protected
eallth information for research unless vwo allow dlnlrn o b.y signing this consent and
auftiorization.


21. Are you required to sign this consent and iullorization and allow the researchers to
collect, use and disclose (give) lo others of your protected benllh Informatloit?

No, and your refusal lo sign will not arect your treatimen, payment, enrollment, or eligibiyII
j;r an l b~ienefiP oLIIsrLJc ibh rcsairch slud). Hoi'.'ver '%u canxI t pjanicipate in this research
,.iMrss, aliathi ir. cotlcorrrf, ,tiF er'd Sio.rlrre 0j' rifr proSectd heakh infonrmatmo hNi
signing this consest/lauthorizotion,


12. Can you reticn or copyyour protected healJt tnformaorinu collcchid, used or dllosed
under this authlorizatlon?

You har thc ri ghr to review and copy your protected health inforrntion. However, you' ill
not be allowed lo do so until altr the study is 1rishei.,


23, Is there a risk Ihnt Nour proleried heaolh Information could be given In ohenrs beyond
your authorizaRton?

Yes. There is a risk thjl iiifoBmacion received by auhorizcd persons could be given to others
beyond yotr authorization and not covered by the law,


24. Can you rccie (cancell) yur nauhortzallon for collection, use and disclosure of your
projected health information?

Yes. You can cancel your authorization .11 any itim before, during cr .iaTr yoLo p;ricip.illor jn
the research. If you cancel, no new information will be collected about y However,
infonnation ihat was already collected may still be used and disclosed to others ifthe
researchers have relied on it locomplete and proi i Vt i.V.LdiI) ol'hc icicarch. You can
cancel by giin5 a writer rcques- with your signalureon [i io the Priinipal In,%clIgatr.


25. How %1ll Ilhe rtesorchLr(sj henefit rrom 3our being In ibis study?

In scrwirl. prcscrninI rIMesearci r culls help dime career ol a scientist. Therefore, the Pricipal
[tIiwesigior mra' bcnclii irthe resulls ofthis study are prtenltd at scientific meetings or in
Sl iellfic jCiumr js.


259-20031 /Rev 0614-04 / Pa6 of 7







77





26. SIgnalares

As a representative of ihis sudy, have explained lo ihe participant the pupose. Ihe
procedures, the possible bent fit, and Ihe risks or ihis rcarch sludy. ihe all'm.nitcs to being
in iliSe tuil, and how Ihc parieipail's protected health information will be collected, used, and
disclosed:




Signaiiun or Person Obtaining Consent and Authorizaion Date



You have been infonned about this sludy's ptupse, procedures, possibLo bmeielt, and risks;
ihe attemntves to being in the sludy, and ihow vyor prniecied ]i llh informilion will be
;oll]ccid, used and disclosed. You have received a copy ofthis Form. You have been given
ilt; opponuilly l Io ak qurslionrs be re[ n siln. and you hjae been iold imwr you can ask other
questions at ant iime

You voluntarily agr i io pirniCipai in ihis study. You liheby auiuhorir c Lhc icolcciion. us aid
disclosuir of your protected halth inromalion as described in sections 15-24 above. By
signing dl.s, J rin, you are nol waiving any afPaur Icgl nJghtl,




Signalure of Person Consenling and Authorizing Dale


250M2003 Rev 06-14-1 f Pa 7 of7
















APPENDIX E
THE SHORT FORM-36 HEALTH SURVEY-SPIRITUAL INVOLVEMENT AND
BELIEFS SCALE


The Short-Form-36 Health Survey



Instructions: This survey asks for your views about your health.

Answer every question by circling your response. If you are unsure about how to
answer a question, please give the best answer you can.




Question I Very
Excellent Good Good Fair Poor

In general would you say you health is: 1 2 3 4 5




Question 2 Much Somewhat About the Somewhat Much
Beter Now' Better Now Same Now WorseNow Worse Now

Compared to one year ago, how would 1 2 3 4 5
you rate your health in general now?












Question 3 The followmg items are about activities you might do during a typical day- Does your heaibh now limit
you in these activities? If so, how much?


Activities Yes, Yes, No, Not
Limited A Lt Limited A Little Limited At All

a. Vigorous activities, such as running, lifting heavy 1 2 3
objects, iFtidcip;tirng in strenuous sports


b. Moderate activities, such as moving a table, pushing a 1 2 3
vacuum clear, bowling, or playing golf


c. Lifting or carrying groceries 1 2 3

d. Climbing several flights of stairs 1 2 3

e. Climbing one flight of stairs 1 2 3

f. Bending, kneeling, or stooping 1 2 3

g. Walking more than a mile 1 2 3

h. Walking several blocks 1 2 3

i. Walking one block I 2 3

j. Bathing or dressing yourself 1 2 3













Question 4

During the past 4 weeks, have you had any of the following; problems with your work or
other regular daily activities as a resrdr of yonr physical health? Yes No


a. Cut down on the amount of time you spent on work or other activities 1 2

b. Accomplished less than you would like 1 2

c. Were limited in the kind of work or other activities 1 2

d. Had difficulty performing the work or other activities (for example, it took 1 2
extra effort)



Question 5
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emolonal problems (such as feeling
depressed or anxious)? Yes No


a. Cut down on the amount of time you spent on work or other activities 1 2

b. Accomplished less than you would like 1 2

c. Didn't do work or other activities as carefully as usual 1 2














Question 6
Not at All Slightly Moderately Quite a Bit Extremely

During the past 4 weeks, to what extent has
your physical health or emotional problems 1 2 3 4 5
interfered with your normal social activities
with family, friends, neighbors, or groups?



Question 7 Very Very
None Mild Mild Moderate Severe Severe

How much bodily pain have you had during 1 2 3 4 5 6
the past 4 weeks




Question 8 A Little Quite
Not at All Bit Moderately a Bit Extremely

During the past 4 weeks, how much did pain
interfere with your normal work including 1 2 3 4 5
both work outside the home and housework)?












Question 9 These questions are about how you feel and how things have been with you during the past 4 weeks. For
each question, please give the one answer that comes closest to the way you have been feeling. How much of the time
during the past 4 weeks --

ALL of Most of A Good Bit Some of A Little of None of
the Time the Time of the Time the Time Time the Time

a. Did you feel full of pep? 1 2 3 4 5 6


b, Have you been a very 1 2 3 4 5 6
nervous person?

c. Have you felt so down in the dumps 1 2 3 4 5 6
that nothing could cheer you up?

d. Have you fll calm and peaceful? 1 2 3 4 5 6


e. Did you have a lot of energy? 1 2 3 4 5 6


f. Have you felt downhearted and I 2 3 4 5 6
blue?

g. Did you feel worn out? 1 2 3 4 5 6


h. Have you been a happy person? 1 2 3 4 5 6


i. Did you feel fired' 1 2 3 4 5 6














Question 10 All of Most of Some of A Litt of None of
the Time the Time the Time the Time the Time

During the past 4 weeks, how much' of the
time has your physical health or emotional
problems interfered with your social 1 2 3 4 5
activities (like visiting with friends,
relatives, etc.)?



Queiion 11

How TRUE or FALSE is each of the Definitely Mostly Don't Mostly Definitely
following srirnements for you? True True Know False False


a. I seem to get sick a little easier than 1 2 3 4 5
other people


b. I am as healthy as anybody I know 1 2 3 4 5


c. I expect my health to get worse 1 2 3 4 5


d. My health is excellent 1 2 3 4 5







84




2) Spiritual Involvement and Beliefs Scale (39 item version) Hatchet atl
Unhraity of Florida)

How strongly do you agi with the fomlowig stalemew.? Plcasmcirdcyour rtspose..

-Srog Mai3y Mi diy sbng
Agm Agc Arr e M NtrMl DBm Disp Dfa Ie


I. I s aside t ea for nredhaLion andloi
sel-rflecOion

2. I n find meaning in times of
hardship.

3.A prsoo can be fuiLled witlbh
pursuing an active spiritual life.

4-1 find isaerilyby accepting hihgs as
they are.

S Som rcxpriencs can be understood
only through ones spirile beliefs.

61do not believe in an afterlife.

7.A spiritual force influnccs Ihe events
in my life.

8. kLuwI n iclIonsl-up wlht ScmnWDe I
can turn lc for spiritual guidance-

9.Pmyrrs do not really change whale
happen.

1 OPatcipating pi spiilual activities
helps me forgive other people.

1 l. fl inner peace when I am in
harmony with nature

12. Ewrylhing happens for eaer
purpose.

131 use contemplation to ge in touch
with rmytru self.


7 6 5 4 3 2 1


7 6 5 4 3 2 1


7 6 5 4 3 2


7 6 5 4 3 2 1


6 5 4 3 2 1


7 6 5 4 3 2 I


7 6 5 4 3 2 i


7 6 5 4 3 2


7 6 5 4 3 '2 I


7 6 5 4 3 2


7 6 5 4 3 2 1














14. My spirual Ie i fills me i ways
ltar maria pcviwssiosr do not.



153 rarely feel connected 1o something
gpear ail anmyself

16.1n i e of despair I can find itle
reason 10 hope.

17t.'W I am sick, I would li~ olber
to pry for mr.

18J 4avc a pcrwOl reblaondhip with a
power greala than myself

19.1 hae had i spiritual cxpaeriene Ith
nitaily lunged mry if

20. Wte I hlp olbe s, I expect nothing
in rcturIn

211 don'l take time to appreiate nature

22.1 depend on a higher power.

231 have joy in my life because of my
iritualiy.

24My reh ionshipwith a hiltr povrcr
hlps me love others moreclmqplktey.

25.SpLilald writings rm-ich mry li~.

26.1 have eperinced hearing after
prayer.

27. My spiritual ustrstandding
coninues to gow.

2&. I am rigl t mre ofin iAnu moM
people.

?9 Maei s;piJriu approaches have linle


7 6 5 4 3 2 t


Strangly MBd Mdly Stronq
Agree Ari Agree et"nl Disagre DisBgr Disa
.7 6 5 4 3 2 1


7 6 5


7 6 5


7 6 5


7 6 5


7 6 5


4 3 2


4 3 2 [


4 3 2 1


4 3 2 I


4 3 2 I


6 5

6 5

6 5


7 6 5


4 3 2 I


6 5

6 5


7 6 5


7 6 5


7 6 :5


4 3 2 3


4 3 2


4 3 2


VMlue.I


__ ~











-vokI.


30. SpiriL halth contibutes to
gphysicl bealhb.

31.1 regularly inertct with others lor
spiinial purpoa.S

32.1 frac on vhar nreds to be chmgvcd
in Ie, no~ on what needs o be cdaged
in other

33. In dillicoU tdrcs, I am still graktcL

341 Ihav been through a tBim ofgreal
sunHring thoal d o spmruia growth.


Srangly Mityl Mi~tly Slroa
Agr Ag re Agre e Dnrgc grec Diagr
7 6 5 4 3 2 t


7 6 5 4 3 _2 1


7 6 5 4 3 2 1


6 5 4 3 2 I


7 6 $


4 3 2 1


Please indicate bow often you do the following:


Atwabs A


35.Wbn I wron sonoItne I make an
effort to npoogizc

36.1 acccpi oaer asthey are.

37.1 sole 4y problem without using
spiritual ssoets.

381 examine my a~ions to see if ty
racl myvahes.


mt Some- Nor AlmI N
wrys uy ims BsaBy w 3 N
6 5 4 3 2 i


7 6 5 4 3 2 1

7 6 5 4 3 2 1


7 6 5 4 3 2 I


39. Iow spiritual a person do you insider yourself? (With "7" being the nIm


1 2 3 4 5 6 7

Searin instmoiaar.
Rvrm sccrme all mplctiy w~mrdW ieasu (3.6A5l.162l2.E9-iTi
i.e. Slitg~ AAgrfte 1. Ag e 2, ..... SuagLy Disagr 7
or Albys L. Albu Alwa 2, ....New. 7















LIST OF REFERENCES


Aarons, H, Hall, G., Hughes, S., & Salmon, P. (1996). Short-term recovery from hip and
knee arthroplasty. The Journal of Bone and Joint Surgery, 8, 555-558.

Affleck, G., Tennen, H., Keefe, F.J., Lefebvre, J.C., Kashukar-Zuck, S., Wright, K.,
Starr, K., & Caldwell, D.S. (1999). Everyday life with osteoarthritis or rheumatoid
arthritis: independent effects of disease and gender on daily pain, mood, and
coping. Pain, 83, 601-609.

American Geriatrics Society. (1998). The management of chronic pain in older persons.
Journal of the American Geriatrics Society, 46, 174-192.

Anderson, H.I., Ejlertsson, G., Leden, I., & Rosenberg, C. (1993). Chronic pain in a
geographically defined general population: Studies of difference in age, gender,
social class, and pain localization. The Clinical Journal ofPain, 9, 174-192.

Bates, M.S., Edwards, W.T., & Anderson, K.O. (1993). Ethnocultural influences on
variation in chronic pain perception. Pain, 52, 101-112.

Brander, V.A., Mullarkey, C.F., & Stulberg, S.D. (2001). Rehabilitation after total joint
replacement for osteoarthritis: An evidence based approach. Physicial Medicine
and Rehabilitation, 15, 175-197.

Burkhardt, M.A., (1989). Spirituality: An analysis of the concept. Holistic Nursing
Practice, 3, 69-77.

Clark, K.M., Friedman, H.S., & Martin, L.R. (1999). A longitudinal study of religiosity
and mortality risk. Journal of Health Psychology, 4, 381-391.

Davis, M.A., Ettinger, W.H., Newhaus, J.M., & Hauck, W.W. (1987). Sex difference in
osteoarthritis of the knee: the role of obesity. Journal of Epidemiology, 127, 1019-
1029.

Diehl, M., Coyle, N., & Labouvie-Vief, G. (1996). Age and sex difference in strategies of
coping and defense across the life span. Psychology and Aging. 11, 127-139.

Ekblom, A., & Rydh-Rinder, M. (1998). Pain mechanisms: anatomy and physiology. In
N. Rawal, (Eds). Management of acute and chronic pain (pp. 1-22). London: BMJ.

Ellison, C.G., & Levin, J.S. (1998). The religion-health connection: evidence, theory, and
future directions. Health Education & Behavior, 25, 700-720.









Erdfelder, E., Faul, F., & Buchner, A. (1996). GPOWER: A general power analysis
program. Behavior Research Methods, Instruments, and Computers, 28:1, 1-11.

Escalante, A., Espinosa-Morales,R., Del Rincon, I., Arroyo, R.A., & Older, S.A.(2000).
Recipients of hip replacement for arthritis are less likely to be Hispanic,
independent of access to health care and socioeconomic status. Arthritis &
Rheumatism, 43, 390-399.

Felson, D.T., (1988). Epidemiology of hip and knee osteoarthritis. Epidemiologic
Reviews, 10, 1-24.

Ferrell, B.A., (2000). Pain management. Clinics in Geriatric Medicine, 16, 853-871.

Fitchett, G., Rybarczyk, B.D., & DeMarco, G.A.(1999). The role of religion in medical
rehabilitation outcomes: a longitudinal study. Rehabilitation Psychology, 44, 333-
351.

Gagliese, L., & Melzack, R.C. (1997). The assessment of pain in the elderly. In D.I.
Mostofsky & J. Lomaranz (Eds.), Handbook ofpain and aging (pp. 69-96). New
York: Plenum.

Gibson, S.J., & Helme, R.D. (1995). Age differences in pain perception and report: a
review of physiologic, psychological, laboratory and clinical studies. Pain Reviews,
2, 111-137.

Hatch, R.L., Burg, M.A., Naberhaus, D.S., & Hellmich, L.K. (1998). The spiritual
involvement and beliefs scale: Development and testing of a new instrument.
Journal of Family Practice, 46, 476-486.

Healy, W. I., Iorio, R., & Lemos, N.J. (2001). Athletic activity afterjoint replacement.
The American Journal of Sports Medicine, 29, 377-388.

Hodges, S.D., Humphreys, S.C., & Eck, J.C. (2002). Effect of spirituality on successful
recovery from spinal surgery. S.,inmhe i Medical Journal, 95,12,1381-4.

Husaini, B.A., Blasi, A.J., & Miller, O. (1999). Does public and private religiosity have a
moderating effect on depression? A bi-racial study of elders in the American South.
International Journal ofAging and Human Development, 48, 63-72.

Katz, J.N., Wright, E.A., Guadagnoli, E., Liang, M.H., Karlson, E.W., & Cleary, P.D.
(1994). Differences between men and women undergoing major orthopedic surgery
for degenerative arthritis. At /th iti, & Rheumatism, 37, 687-694.

Keefe, F.J., Lefebvre, J.C., Egert, J.R., Affleck, G., Sullivan, M.J., & Caldwell, D.S.
(2000). The relationship of gender to pain, pain behavior, and disability in
osteoarthritis patients: The role of catastrophizing. Pain, 87, 325-334.









Kim, J., Heinemann, A.W., Bode, R.K., Silwa, J., & King, R.B. (2000). Spirituality,
quality of life, and functional recovery after medical rehabilitation. Rehabilitation
Psychology, 45, 365-385.

Koenig, H.G., George, L.K., Blazer, D.G., Pritchett, J.T., & Meador, K.G. (1993). The
relationship between religion and anxiety in a sample of community-dwelling older
adults. Journal of Geriatric Psychiatry, 26, 65-93.

Koenig, H.G., George, L.K., Hays, J.C., Larson, D.B., Cohen, H.J., & Blazer, D.G.
(1998). The relationship between religious activities and blood pressure in older
adults. International Journal of Psychiatry in Medicine, 28, 189-213.

Koenig, H.G., George, L.K., Meador, K.G., Blazer, D.G., & Dyck, P.B. (1994). Religious
affiliation and psychiatric disorder among Protestant baby boomers. Hospital and
Community Psychiatry, 45, 586-596.

Koenig, H.G., & Larson, D.B. (1998). Use of hospital services, religious attendance, and
religious affiliation. SNntlihei Medical Journal, 18, 925-932.

Koenig, H.G., McCullough, M.E., & Larson, D.B. (2001). Handbook of religion and
health, New York: Oxford University Press.

Lawrence, R.C., Helmick, C.G., Arnett, F.C., Deyo, R.A., Felson, D.T., Giannini, E.H., et
al. (1998). Estimates of the prevalence of arthritis and selected musculoskeletal
disorders in the United States. At i/il ti% & Rheumatism,41,5, 778-799.

Lazarus, R.S., DeLongis, A., Folkman, S., & Gruen, R. (1985). Stress and adaptational
outcomes. American Psychologist, 40, 770-779.

Levin, J.S., & Chatters, L.M. (1998). Religion, health, and psychological well-being in
older adults. Journal ofAging and Health, 10, 504-531.

Levin, J.S., & Vanderpool, H.Y. (1990). Is religion therapeutically significant for
hypertension? Social Science Medicine, 29, 69-78.

Matthews, D.A., McCullugh, M.E., Larson, D.B., Koenig, H.G., Swyers, A., & Milano,
M.G. (1998). Religious commitment and health status. Archives of Family
Medicine, 7, 118-124.

McFadden, S.H., & Gerl, R.R. (1990). Approaches to understanding spirituality in the
second half of life. Generations, 23, 35-38.

McFadden, S. H., & Levin, J.S. (1996). Religion, emotions and health. In C. Magi &
S.H. McFadden (Eds.), Handbook of emotion, adult development, and aging (pp.
349-365). San Diego, CA: Academic Press.









McGuigan, F.X., Hozack, W.J., Moriarty, I, Eng, K., & Rothman, R.H. (1995).
Predicting quality of life outcomes following total joint arthroplasty. The Journal of
Arthroplasty, 10, 742-7.

Meador, K.G., Koenig, H.G., Hughes, D.C., Blazer, D.G., Turnbull, J., & George, L.K.
(1992). Religious affiliation and major depression. Hospital and Community
Psychiatry, 43, 1204-1208.

Mobily, P.A., Herr, K.A., Clark, M.K., & Wallace, R.B. (1994). An epidemiologic
analysis of pain in the elderly. Journal ofAging andHealth, 6, 139-154.

Norman-Taylor, F.H., Palmer, C.R., & Villar, R.N. (1996). Quality of life improvement
compared after hip and knee replacement. The Journal of Bone and Joint Surgery,
78-B, 74-7.

Paragment, K.I., Ensing, D.S., Falgout, K., Olsen, H., Reilly, B., Van Haitsma, K., &
Warren, R. (1990). God help me (1): Religious coping efforts as predictors of the
outcomes to significant negative life events. American Journal of Community
Psychiatry, 18, 793-824.

Pargament, K.I., Smith, B.W., Koenig, H.G., & Perez, I. (1998). Patterns of positive and
negative religious coping with major life stressors. Journal for the Scientific Study
ofReligion, 37, 710-724.

Pasero, C., Portenoy, R.K., & McCaffery, M. (1999). Opoid analgesics. In M. McCaffery
& C. Pasero (Eds.), Pain: Clinical manual (pp. 161-299). St. Louis, MO: Mosby

Paulson, P.E., Minoshima, S., Morrow, T.J., & Casey, K.I. (1998). Gender differences in
pain perception and patterns of cerebral activation during noxious heat
stimulationin humans. Pain, 76, 223-239.

Pellino, T.A., Preston, A.S., Bell, N., Newton, M.J. & Hansen, K. (2002). Complications
of orthropaedic disorders and orthopaedic surgery. In S.W. Salmond & T.A.
Pellino (Eds.), Orthopaedic nursing (3rd ed. pp. 234-270). Philadelphia: W.B.
Saunders.

Porter, F.L., Malhotra, K.M., Wolf, C.M., Morris, J.C., Miller, J.P., & Smith, M.C.
(1996). Dementia and response to pain in the elderly. Pain, 68, 413-421.

Praemer, A., Furner, S., & Rice, D.P. (1992). Musculoskeletal conditions in the United
States. Rosemont, IL: American Academy of Orthopaedic Surgeons.

Praemer, A., Fumer, S., & Rice, D. P. (1999). Musculoskeletal conditions in the United
States. Rosemont, IL: American Academy of Orthopaedic Surgeons.

Pressman, P.A., Lyons, J.S., Larson, D.B., & Strain, J.J. (1990). Religious belief,
depression, and ambulation status in elderly women with broken hips, American
Journal of Psychiatry, 6, 758-760.